Final Reflections - American Dental Hygienists' AssociationFinal Reflections MA Gaston Mary Alice...

Source: Journal of Dental Hygiene, Vol. 80, No. 1, January 2006

Copyright by the American Dental Hygienists' Association

Final Reflections

MA Gaston

Mary Alice Gaston is emeritus professor of dental hygiene at the University of Tennessee Health Science Center, a past president ofthe American Dental Hygienists' Association, and current editor-iin-chief of the Journal of Dental Hygiene.

Keywords: dental hygiene research, dental hygiene research journal, leadership change

As I prepare this editorial in late December of 2005, I am keenly aware that this is my final opportunity to speak to Journalof Dental Hygiene readers as Editor-in-Chief. While I have looked forward to retiring from this position for some time,the decision to give up leadership of the Journal was not easy. I suppose other former Journal editors who really lovedthe work must have had similar feelings upon leaving the position. Furthermore, I have recently found myself wonderingif as editor I did everything I could have done to make each issue of the Journal the very best possible. I can only hopethat the record will speak kindly of my efforts. After reflecting back on my experience as editor, I have chosen a few finalthoughts to share with you hoping that they might be helpful to those of you who are responsible for maintaining theintegrity of the Journal of Dental Hygiene.

When I was appointed editor, I had no idea I would stay in the position for seven and a half years. While I did not givemuch thought in the beginning to how long I would be the editor, I did think a lot about the importance of the Journal ofDental Hygiene to our profession's continuing growth and development. I remembered that in 1926 one of the first thingsthe newly established American Dental Hygienists' Association (ADHA) did was to establish a professional journal tokeep its members informed. For these reasons, I realized that becoming the Journal of Dental Hygiene editor was anenormous responsibility and an extraordinary privilege that only a very few fortunate people experience. Above all, I knewthat I had best not mess up in such a highly visible position. There are many reasons to believe that the Journal is strongernow than it was when I took over as its editor July 1, 1997. I do not claim the credit for this, but share it with others suchas the ADHA talented staff editors, dedicated members of the Journal review board, authors, and ADHA leaders andmembers who offered encouragement all along the way. I encourage everyone to give the same level of support to the neweditor-in-chief as she takes on the challenges of leading the Journal forward over the coming years. The knowledge ofyour support should give her the confidence she will need to accomplish some of the important initiatives that will makeour Journal even better.

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As editor, my primary goal from the very beginning was to see that the Journal of Dental Hygiene fulfilled its purpose asthe ADHA refereed, scientific publication, and the dental hygiene profession's premier research journal. I was particularlysensitive to the need to publish reports of original and innovative work that added to the dental hygiene body of knowledgethrough scientific inquiry in basic, applied, and clinical research. In recent years I was more and more impressed by thepublic health related scientific studies and projects being undertaken by dental hygienists in various settings all over theworld. I felt strongly the importance of documenting such work in the literature, and therefore, encouraged individualinvestigators to submit their reports for publication in JDH. This part of my work was very satisfying because I wasprivileged to read such reports before everyone else. It was really exciting to me personally to know who was doing whatkind of work, where, and when. I believe it is urgent that this dental hygiene research be encouraged, continued, andreported in JDH. I know that our new editor-in-chief feels a strong commitment to continue to focus on this primarypurpose of the Journal of Dental Hygiene and I hope you will support her efforts in this regard.

I want to talk a bit about the Journal of Dental Hygiene format. No one is more aware than I that changing to the electronicformat had a dramatic affect on some of our readers and may have resulted in fewer people actually reading the Journalregularly. While I know that the electronic format is here to stay, I am confident that the new editor-in-chief plans toexplore ways to ease the transition from paper copy to online copy and to increase JDH readership. The major point Ithink we should remember is that the Journal contains high quality dental hygiene scientific reports, regardless of whetherit is delivered in paper or online format. Yes, it may take a little more effort to access those reports online, but accessingthem is worth the effort. It may also mean that dental hygiene educators will have to require their students to regularlyaccess the Journal online to complete reading assignments as a part of regular classroom and clinical education so thatthey will develop the habit of reading it online while they are students. It also may mean that the ADHA will have todevelop ways to remind subscribers when issues are published and available. We simply must read the latest dental hygieneresearch being reported in the Journal of Dental Hygiene because that is where the majority of such research is beingpublished. We owe it to our profession, don't we?

Finally, I want our readers and ADHA leaders and members to know what a pleasure and honor it has been to serve aseditor. From the very first, you welcomed me into your hearts and gave me your complete trust and support. I will alwaysbe grateful for the kindness and the encouragement you expressed to me throughout my tenure. I thank the members ofthe editorial review board for their commitment to the Journal and to mentoring authors. I particularly applaud you forcompleting an unbiased review of each manuscript, and for the fact that you do this work as a service to our profession. Iappreciate the cooperative attitude of the many authors who have submitted manuscripts during my tenure. I thank youbecause you have taken our suggestions and criticisms as constructive and have used them wisely, making our job easier.I want to especially thank each of the ADHA staff editors who have worked with me on the Journal of Dental Hygiene.You have each been different, but each very talented and a pleasure to work with.

Over the last month, I've thought of a scene in the movie, "Lonesome Dove," in which the colorful character, Gus, laydying from wounds sustained in a brutal fight with the Indians. In that scene, Gus knew he was near the end of his lifeand, being a very brave man, was willing to accept the facts as they were. To express his life and how he had lived it, hesaid, "It's been one hell of a ride." While I certainly don't think I'm nearly at the end of my life, I may very well havecompleted the last big assignment of my dental hygiene career when I retired as editor of the Journal of Dental Hygiene.Therefore, like Gus, I'm pleased to say, "My dental hygiene career has been one heck of a ride."

My final wish is that Rebecca Wilder will treasure the position of editor-in-chief of the Journal of Dental Hygiene andthat she will be encouraged by the support of her peers in dental hygiene as I have been over the past seven and a halfyears.

Journal of Dental Hygiene, Vol. 80, No. 1, January 2006


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Upfront

Katie Barge

Katie S. Barge is staff editor of the Journal of Dental Hygiene and staff writer for Access

Periodontal Disease may be the Heart of Cardiovascular Problems

Brushing, flossing and regular dental checkups may help keep the heart healthy, reported experts in Circulation, the journalof the American Heart Association.

"People who have chronic infections-and gum disease is one of the major chronic infections-are at increased risk later inlife for atherosclerosis [hardening of the arteries] and coronary heart disease," said Dr. Richard Stein, American HeartAssociation spokesman and director of preventive cardiology at Beth Israel Medical Center in New York City.

Why? Chronic periodontal disease, a persistent bacterial infection affecting the gums and bone supporting the teeth, setsoff an inflammatory process that aggravates and contributes to the build-up of cholesterol-rich plaque on artery walls.

"What you are really talking about here is an inflammatory process. The body is an amazing machine that handles chronicinflammation, whether it is in the mouth or in the heart, in a similar manner," said JoAnn Gurenlian, RDH, PhD.

"Literature suggests that during periodontal inflammation, pathogens enter systemic tissue, invade the heart and coronaryartery cells, induce platelet aggregation, and can cause thrombus formation. Therefore, the two diseases [periodontaldiseases and cardiovascular disease] share common risks and etiologies," said Gurenlian.

According to Gurenlian, the infection that causes periodontal disease and sets up an inflammatory response leads to anincrease in cellular mediators. One such mediator, C-reactive protein (CRP), is produced by the liver during periods ofinflammation and causes inflammation of the arteries.

"Elevation of CRP damages the smooth muscles of the blood vessels, which can precipitate a cardiovascular event. WhenCRP is produced, the arterial walls that have cholesterol plaques deposited become unstable and some may rupture. Ifthey do rupture, a clot can form leading to stroke or myocardial infarction," said Gurenlian.

Experts have known about the periodontal-cardiovascular link for about ten years, according to Stein. "It's become a biggerproblem in general because we're having fewer cavities due to fluoride and we're living longer," said Stein. "So, more andmore, what's making us lose our teeth is periodontal disease."

Fortunately, periodontal disease is preventable. Like exercising and eating healthy, Dr. Stein advises his patients who areworried about their risk for heart attack to incorporate good periodontal care into their everyday preventative strategy.

Gurenlian recommends that those who are at risk use a toothpaste with both antibacterial and anti-inflammatory properties."The best and most simple things we can do it take care of our oral health. The goal is to reduce infection and inflammationas much as possible."

One lucky group of adults-those with dentures-do not have to worry about periodontal troubles. "In order to have aninfection of your gums, you need to have teeth," said Stein.

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"Taking care of your teeth is part of general good health and quality of life, and it may also have a protective role for yourheart," said Stein.

Acetaminophen is Leading Cause of Acute Liver Failure

Liver toxicity from Acetaminophen poisoning is the number one cause of acute liver failure in the United States, accordingto researchers reporting in the December issue of Hepatology.

Most at risk are acetaminophen users with depression, chronic pain, alcohol/narcotic use, as well as those who take multipleacetaminophen-containing products at the same time, wrote the researchers.

"Education of patients, physicians, and pharmacists to limit high-risk [acetaminophen] use settings is recommended,"wrote Anne M. Larson, MD, of the University of Washington, and colleagues at 21 other US Centers.

There is, however, no need to panic, because acetaminophen-associated liver toxicity is rare, and the drug itself is nottoxic, wrote John G. O'Grady, MD, of the Institute of Liver Studies at King's College Hospital in London, in anaccompanying editorial.

Rather than boycotting acetaminophen-contain products all together, O'Grady, like Larson and her colleagues, recommendedan increase in education. "Education initiatives to highlight the range of preparations containing acetaminophen, togetherwith reiteration of advice on maximum daily dosing, have potential benefits, especially with respect to unintentionaloverdosing."

Acetaminophen, the active ingredient in Tylenol and a variety of other pain killers is widely available in over-the-counterpreparations for headaches, colds, allergies, osteoarthritis, and several other conditions.

Consistent use of as little as 7.5 grams of acetaminophen a day could lead to severe hepatic injury, wrote Dr. Larson andher colleagues. Be it intentional or accidental, consuming more than the package-recommended four grams per day isconsidered acetaminophen overdose, which has been associated with severe hepatic necrosis leading to acute liver failure.

Although some people deliberately take toxic doses of acetaminophen in an attempt to commit suicide, others haveunintentionally accumulated high, toxic levels of acetaminophen when taking, for example, Tylenol for a headache and asecond acetaminophen-containing product for cold symptoms.

According to the study's authors, N-acetylcysteine administered within 12 hours of ingestion of acetaminophen can preventliver injury; however, many people are unaware of this course of action.

Both Larson et al and O'Grady suggest that a strategy restricting but not banning over-the-counter sales of medicationscontaining acetaminophen may be necessary to prevent accidental overdose.

A similar approach in the United Kingdom led to a 30% reduction in patients with severe acetaminophen-induced acuteliver failure after just four years.

Women, Protect Against Heart Disease and Osteoporosis BEFORE Menopause

Stress and fluctuating hormone levels can cause problems for women long before menopause, suggests a new study.Traditionally, it has been thought that a woman is protected from heart disease and osteoporosis until she goes throughmenopause. However, new research with monkeys questions that belief and suggests that the time for women to startprotecting their heart and bones is during perimenopause, or preferably, even earlier.

"Most women think they don't have to worry much about chronic health problems until perimenopause or menopause,"said Jay Kaplan, head of the section of comparative medicine at Wake Forest University School of Medicine. "But there'sa high-risk trajectory that women can get on in their reproductive years that sets the stage for later problems."



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During perimenopause, aka premenopause, which can start as early as age 35, a woman's body starts making less of thehormones estrogen and progesterone. In previous monkey studies, Kaplan found that stress reduced estrogen levels andinitiated the buildup of plaque in the blood vessels.

According to Kaplan, the quality of ovarian function-the way in which the body produces estrogen and progesterone- inthe premenopausal period can contribute to a woman's health status later in life. "Ovarian function varies quite a bit duringthe premenopausal years. And it turns out that reproductive function in both women and monkeys is easily impaired bystress," said Kaplan.

Many women never realize their ovarian function is impaired because they continue to cycle normally, said Kaplan.Unfortunately, this means that women are unknowingly being exposed to varying levels of estrogen, which can have anegative effect on both heart and bone health.

"The reality is a lot of heart health begins before menopause," said Dr. Steven Goldstein, an obstetrician/gynecologist atNew York University Medical Center. "Perimenopuase is an excellent opportunity to begin a self-assessment and medicalreport card. Develop a plan with your doctor for your overall health, diet and lifestyle for the second half of your life."

Until more is research has been completed on the effects of premenopausal estrogen therapy, Kaplan recommends thatwomen try to reduce stress wherever possible.

"Stress does matter. In fact, it matters in ways that women probably don't recognize. Try to learn new coping skills forstress, and extend your social networks," advised Kaplan.



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Review of: Culture and Clinical Care

Cassandra Holder-Ballard

Reviewed by Cassandra Holder-Ballard, RDH, MPA, associate professor of dental hygiene at the University of Tennessee, HealthScience Center, in Memphis, Tennessee.

Culture and Clinical Care

1st Edition

Lipson JG and Dibble SL

UCSF Nursing Press, 2006

San Francisco, California

487 pages, indexed, soft cover

ISBN 0-943671-22-1

$33.95

Culture and Clinical Care is a guidebook designed for use by clinicians who work with culturally diverse clients. Thissoft-backed text is not designed to be used as an instructional textbook, but rather as a starting point in understanding avariety of cultural/ethnic groups.

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The book's introduction is entitled, "Providing Culturally Appropriate Health Care." This section provides a frameworkfor understanding the significance culture plays in the provision of health care. The subtopics in this section are "Limitationsof Information," "Sources of Diversity," "Variations in Communication," and "Communication and Interpreters."

This book is composed of 35 chapters. Each chapter addresses a specific cultural/ethnic group. The cultural groups wereselected based on population size; according to the United States (U.S.) Census each group numbers at least 100,000.Chapters are arranged alphabetically, beginning with Afghans and ending with (former) Yugoslavians. Each chapter isauthored by 1 to 3 individuals who are members of the cultural/ethnic group, or are uniquely connected to the group. Mostof the authors are nurses with advanced degrees. Other authors have advance degrees in areas such as public health orsocial anthropology.

Chapters follow a common sequence. There are 12 major headers, and each contains 3 to 15 subtopics. The first headeris "Culture/Ethnic Identity". There are three subtitles for this header. The first is a discussion of the preferred terms foridentifying members of this group. Next, a census report of the population is provided, including where the largest numbersreside. Some other interesting headers are "Spiritual/Religious Orientation," "Food Practices," "Symptom Management,"and "Death Rituals."

"Communication" appears to be the most involved section for every chapter. Discussions in this area include majorlanguages and dialects, tone of voice, styles of speech, and the use of interpreters. Written communication is also addressed,regarding literacy assessment and consents. Last, nonverbal communication is addressed. Some of the subtitles for thistopic are "Eye Contact," "Personal Space," "Meaning of Silence," "Gestures," and "Orientation of Time."

Other extensive sections are, "Birth Rituals," "Developmental and Sexual Issues," "Family Relationships," and "IllnessBeliefs." The "Birth Rituals" section covers pregnancy to delivery as well as baby care. "Developmental and Sexual Issues"section provides insight on attitudes toward birth control, STDs, abortion, and sexual orientation. The "Family Relationships"section offers information about family structure, decision making, roles of family members, and expectations of and forchildren. Finally, the "Illness Beliefs" section discusses the concept of health and prevention and ends with common healthproblems.

The editors stress that there is considerable variation in every cultural group. They caution that chapters in this book shouldnot be used as blueprints for patient characteristics. Their purpose is to alert clinicians to potential factors that they shouldconsider in providing appropriate care.

Culture and Clinical Care is an excellent resource for many health care providers, especially those who deliver directpatient care. The text provides easy access to information pertaining to specific cultural/ethnic groups. However, the readermust remember that the information provided is not a substitute for individualized patient interaction.



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Review of: Essentials of Dental Hygiene: Preclinical Skills

Patricia A Frese

Reviewed by Patricia A. Frese, RDH, MEd, associate professor of dental hygiene at the University of Cincinnati, Raymond WaltersCollege, in Cincinnati, Ohio.

Essentials of Dental Hygiene: Preclinical Skills

1stEdition

Cooper MD, Wiechmann L

Pearson Prentice Hall, 2005

Upper Saddle River, New Jersey

321 pages, illustrated, indexed, soft cover with CD-ROM

ISBN 0-13-094104-2

$38.60

The authors' intent for this text is to have the first-year, first-semester dental hygiene student learn the basic skills necessaryto provide initial dental hygiene care in the clinical setting. The authors recognize that additional skill sets are requiredfor comprehensive care and are planning a follow-up textbook covering these additional skills and services. The text iswritten in an outline format that the first-time reader can easily read and scan when reviewing the material. The 10 chapters,written by the authors and expert contributors, are presented in the order of patient treatment. While this text is primarilywritten for the dental hygiene student, it is of value to the dental hygiene practitioner who wants a skills review, and forfaculty calibration as well.

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The focus and design of the text make the information and skills immediately applicable to patient treatment. The chaptersbegin with a glossary of key terms with definitions and a list of learning objectives. The core content of each chapter ispresented in a step-by-step sequence with enough background information to contribute to critical thinking, thus avoidingperformance of skills without understanding. There are "Preclinical Tip" boxes throughout, which provide interestinginformation that will strengthen the reader's knowledge. The boxes are cleverly subtitled to match the intent of each chapter.There are tables, charts, diagrams, photographs, and sample forms that are supported by and help to further explain thewritten text. The chapters end with skill sheets and multiple-choice questions that can by used by the student for practiceand/or by the instructor for evaluation. A list of references completes each chapter.

The photographs in the text are in black and white. There are pages at the end of the text that have some of these photographsin color so the learner can begin to appreciate the importance of normal and abnormal coloration of the head and neckregions.

Additionally, there is a CD-ROM with the text. The reader is directed to this feature at the beginning of every chapter.The CD contains a photo gallery that has color versions of the black and white photographs presented in the text. Thisallows the reader to view the correct coloration in a more cost-effective manner than a full-color text. The CD also containsvideo clips of the skills. These techniques videos include infection control, extra- and intraoral examinations, charting,instrumentation for both right- and left-handed practitioners, blood pressure measurement, polishing, oral physiotherapy(OPT) aids, and fluorides. QuickTime is necessary to view these short video clips and can be downloaded from the CD.The student can use the CD as self-study or the instructor can present the information in class.

Overall, the text is applicable to a wide audience. The information is complete and current. The CD-ROM is a usefuladdition and makes good use of current technology to provide additional information while keeping costs reasonable. Forthe second edition of the text, the authors should consider providing the answers to the review questions as well as thepage numbers where the material is presented. This will make the questions more useful to the beginning learner as wellas for the student reviewing for board exams.



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Review of: Oral Pathology for the Dental Hygienist

Joan C Gibson-Howell

Reviewed by Joan C. Gibson-Howell, RDH, MSEd, EdD.

Oral Pathology for the Dental Hygienist

4thEdition

Ibsen OAC, Phelan JA

Saunders, 2004

St. Louis, Missouri

395 pages, illustrated, indexed

ISBN: 0-7216-9946-4

$72.95

The fourth edition of Oral Pathology for the Dental Hygienist is an affirmation of the popularity of the text and the authors'desire to produce a valued resource for the dental hygiene learner and teacher of oral pathology. As stated in the preface,this text now includes 10 chapters which exemplify the authors' efforts to adequately cover, enhance, expand, and clearlyrelay information to students and practitioners. For example, in the previous edition, the chapter on immunology waslonger, but is now separated into 2 chapters: Chapter 3, "Immunology" and Chapter 4, "Infectious Diseases." In addition,although nonneoplastic bone diseases information was included throughout the previous edition, Chapter 8 was added tothis edition and is specifically dedicated to this topic.

This full-color text of clinical photographs and photomicrographs enhances the transference of didactic knowledge intoclinical application. The depth and scope of the text information is presented in a clear, succinct manner that is

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understandable, provides appropriate information to the dental hygiene student, and is a useful reference to the practitioner.An oral pathologist who used the text to teach dental hygiene courses reports that specific features make this text teacher-and student-friendly. These features include the detailed objectives and vocabulary at the start of each chapter, reviewquestions at the end of each chapter with corresponding answers at the end of the book, a comprehensive and valuedsynopsis of the chapter information at the end of each chapter, and a text glossary. All were a definite asset to the learnerand to the teacher of the course, who also comments that the CD-ROM was a prized resource. The students appreciatedhaving the images for study on the computer and in the text.

The quality contrast and density of the radiographs clearly depict abnormalities and pathologies of which the clinicianmust be knowledgeable. Throughout the chapters, accurate references are made to figures that correspond to the text. Forexample, Langerhans cell disease is clearly depicted histologically, radiographically, and clinically. Illustrations enhancethe clarity of the information and are included as appropriate throughout the chapter readings.

This colorful textbook with corresponding CD-ROM definitely meets its goal to be an excellent oral pathology text fordental hygiene students, practitioners, and teachers. It is practical, user-friendly, and comprehensive. Thank you to theauthors and their contributors for their excellent efforts in making such a useful text for dental hygiene professionals.



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Review of: Paediatric Cariology

Jackie Carpenter

Reviewed by Jackie Carpenter, CDA, RDH.

Paediatric Cariology

Volume 14 in a series of 36. Paediatric Dentistry/Orthodontics series Volume 2

Deery C, Hosey MT, Waterhouse P

Quintessence, 2004

London, England

136 pages

ISBN: 1-8509-7073-4

$54.00

In neatly organized chapters, this volume of the Quintessential Dental Practice series clearly states the facts about, andthe needs and ideas for improvements of, the oral health of children in the United Kingdom,. Although much of theinformation differs from the United States, the topic of pediatric cariology is covered, from understanding the need totechniques used in preventing and managing caries in children. The photos are clear and the illustrations complement thetext. Although there are some slight spelling or word differences, the meanings are understood by the context. This volumementions state-of-the-art technology such as the Diagnodent lasers and fiber optics to detect caries. It briefly includeslasers, air abrasion, and ozone technology in management of caries. The references and suggestions for further reading

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are relatively current, from the past 3 to 10 years. This volume has many topics and facts appropriate for dental hygieniststo refresh their knowledge and gain understanding of oral health issues in children, although there are several chaptersthat share clinical details for dentists, making this volume inappropriate for patients.

Pediatric dentistry in the United States does have its differences in many aspects from the United Kingdom. The mostsignificant difference is that many parts of the United Kingdom have the highest prevalence of dental caries, whereas inthe United States, which has used preventable measures for years, especially fluoridated water, dental caries are almostcompletely preventable. Many dental practitioners in Western Europe treat pediatric toothaches by removing the tooth,which creates another issue to deal with when a space is left. Due to socioeconomic conditions in the United Kingdom,saving the tooth may not be an option, as this book explains.

The book uses the International Dental Federation (FDI) tooth numbering system, which is also called the International.This system is two-digit, by numbering the quadrants 1-4, and numbering the teeth 1-8. In the United States, the UniversalTooth Numbering System is used, which numbers the teeth from 1 to 32 for adults and A to T for children. Chapter 4mentions a caries prevention toolkit for children and recommends Xylitol chewing gum, chlorhexidine, and fluoridevarnish, along with diet modification and sealants. The United States is just now experiencing the use of Xylitol; it canbe found in health food stores in the form of gum, mints, or packets, and in Trident chewing gum. Xylitol is a 5-carbonsugar alcohol that is not fermentable by oral bacteria and inhibits Streptococcus mutans. In the United States, chlorhexidineis more regularly prescribed for adults than children as an adjunct to tissue management in patients with periodontal disease.In the United States, the Food and Drug Administration has approved fluoride varnish as a "cavity liner" and a desensitizingagent. Its use as a dental caries preventive agent is considered "off label." Fluoride varnish has a long history of usethroughout Europe, Canada, and the Scandinavian countries since the 1980s.

Chapters 5 through 8 contain techniques used by dentists in both the United Kingdom and the United States. There aresome techniques that American dentists may find interesting in dealing with the child patient. Chapter 5 mentions theAtraumatic Restorative Treatment (ART) technique, which treats decay as early as possible by using only hand instrumentsfor excavating and a finger to condense glass-ionomer cement for fillings. In the United States, the ART technique usedwidely is air abrasion microdentistry, which treats decay as early as possible with a gentle spray of air and powder mixthat removes decay with no needle or drill, and fills it with a tooth-colored resin. Chapter 7 promotes pulp therapy as analternative to extracting decayed teeth in the primary dentition. The introduction mentions the recent controversy andchanges on the use of formaldehyde in humans for pulp therapy by the International Agency for Research on Cancer,which confirms the carcinogenic effects of formaldehyde in humans and promotes aldehyde-free techniques in the UnitedKingdom. They are currently using ferric-sulfate instead of formocresol. Chapter 8 describes a technique called "discing"that the United Kingdom also uses. This technique is used to reduce recurrent caries in primary teeth by removinginterproximal caries with abrasive discs. This reshapes the teeth to produce easier access for cleansing, although the resultsare not aesthetically pleasing, as the chapter describes.

As a dental hygienist, I found this volume in the Quintessential Series informative and interesting. It expanded my viewof children's oral health concerns and access to care in countries other than my own and reminded me of my role as anoral health educator, which was stressed by my instructors in dental hygiene school. I would recommend this volume todentists, dental hygienists, and dental assistants.



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Spanish for Dental Professionals - A Step by Step Handbook

Judy Campbell Karpis

Reviewed by Judy Campbell Karpis, RDH, EdD.

Spanish for Dental Professionals - A Step by Step Handbook

Bender D, Maier M, Stern I

University of New Mexico Press, 2005

Albuquerque, New Mexico

107 pages, illustrated, CD-ROM

ISBN: 0-8263-3613-2

$21.95

"You can't judge a book by its cover" comes to mind when reading over Spanish for Dental Professionals - A Step by StepHandbook. It depends upon what your level of understanding of Spanish is and what your expectations are when readingthis book for personal and/or professional reasons. If you are an absolute beginner and have very little understanding ofthe Spanish language, then perhaps this book is for you. If you are, however, a seasoned resident of a bilingual community,a 100-page book will not compensate for years of missed language skills.

What the writer of this book attempts to do is to teach conversational Spanish in the context of one paperback book andCD-ROM, something that I haven't been able to learn completely through years of practice, coursework, and living fullyimmersed in a predominantly Spanish speaking culture.

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The book starts out very logically, explaining that it should be used by small groups of learners who want to work togetherto improve their dental health-related spoken Spanish skills. Further explained is that there should be a "facilitator," nota teacher, who has the best Spanish language skills of the group. It turns out by reading on, that the book is not really"Spanish for Dental Professionals", but learning to speak Spanish FOR dental professionals who want to learn conversationalSpanish.

As described in the book, the authors urge the group of learners to meet once a week at lunch. Also listed in the suggestionsfor the learner are some excellent adjunctive activities, such as visiting a grocery store, restaurant, or church service whereSpanish is spoken. Also recommended by the writers is for the learner to "build a personal library of Spanish resources."This suggestion confirms what eventually became evident to me, this book cannot stand on its own as a means of learningdental Spanish or conversational Spanish.

While the book is technically and factually correct, it may not cover some of the important sayings that are used by variousgroups of Spanish speaking individuals in the different parts of the United States.

The authors clearly and adequately cover the topics included in the book. The accompanying CD also adds much neededinformation. However, it is not a reference book, as indicated by the description on the cover. One major flaw is that thereis no comprehensive chart of dental terms for dental hygienists. Also, the cover states that the book/CD are meant to bepart of a one hour per week, six week long training course. Without additional resources, it is unrealistic to expect toenhance conversational Spanish skills in that period of time.

Herein lies the problem. For instance, on page 17, there is a chart listing "New Expressions" or Expresiones nuevas:Aprendiendo sobre la familia (Learning about the Family). The chart contains very useful information about how to askthe patient their name, their mother's name, etc. This is all fine and well if the patient answers you in one word sentencesand doesn't elaborate. However, if the patient says back to you, "Me llamo Jose; mis amigos llama me Gordo," you mayjust be in trouble. You might find yourself smiling and shaking your head and wondering what the heck they just said.'Ok, I got the part about "My name is Jose, but what else did he say?"'

Again, on page 21, there is a wonderful chart which tells the dental professional basic sayings that you might want to sayto the patient on the first visit. "Abra la boca, por favor" is a good one, for example, if you just need the patient to opentheir mouth. "Saque la lengua" is great if you are doing a cancer screening and need them to stick out their tongue.Unfortunately, if they talk back in their native language, you will have a difficult time understanding what they are saying.

The level of writing is appropriate for all levels of readers, especially for college-educated dental hygienists. The photosand illustrations complement the text, especially the charts. The flash cards at the end of the book are a "must" for anyonewho takes on the basics of Spanish.

The book includes very important information, such as the months and seasons, as well as the numbers in Spanish. Includedin the book, however, is a "Immigrant Experience Game" which seems somewhat out of place. During the game, theplayers can get their work visa revoked, get deported, arrive via JFK or earn their GED - none of which has to do withSpanish for the dental professional.

One of the other game pieces says, "You must speak fluent English," and that one makes me almost laugh out loud. Herein South Florida, it is we Americans that must speak fluent Spanish. Spanish has become part of our culture. In order towork here, you MUST speak Spanish fluently. It is not always the other way around. It is not unusual in Miami and MiamiDade County, especially, to walk into a business and not have ANYBODY speak English. This makes the struggle for usto learn perfect Spanish even more immediate and important.

What parts stand out as far as the book is concerned? The CD-ROM is an excellent adjunct to the book and the flash cardsin the back of the book are good for memory exercises.

The book does succeed in its goal to "be used in emergency situations or as a source of phrases to make routine visits morecomfortable for patients." As far as meeting its stated goal, "to help dentists, dental hygienists, and other dental personnelcommunicate with Spanish-speaking patients," that may be a stretch for this book alone.



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Comparison of Muscle Activity Associated with StructuralDifferences in Dental Hygiene Mirrors

Melanie Simmer-Beck, Kimberly K Bray, Bonnie Branson, Alan Glaros and Jeff Weeks

Melanie Simmer-Beck, RDH, MS, Assistant Professor, Division of Dental Hygiene, University of Missouri-Kansas City. Kimberly KrustBray, RDH, MS, Professor, Graduate and Degree Completion Program director, University of Missouri-Kansas City. Bonnie G. Branson,RDH, PhD, Associate Professor, Division of Dental Hygiene, University of Missouri-Kansas City. Alan Glaros, PhD, Associate Deanand Professor, Kansas City University of Medicine and Biosciences. Jeff Weeks, BS, OTR/L, CEAS is managing partner of Weeksccupational Wellness, LLC in Shawnee, Kansas. He is adjunct faculty with the University of Missouri-Kansas City Dental Schoolgraduate program where he assists graduate students doing research in the area of ergonomics and Penn Valley Community CollegeOccupational Therapy Assistant Program.

Purpose. Ergonomic studies suggest that the commonly used pinch grasp, held in a static position, is a contributingfactor for dental Hygienists' development of work-related musculoskeletal disorders (WMSDs) such as carpal tunnelsyndrome (CTS), Trigger Thumb, de Quervain's stenosing tenosynovitis, and carpometacarpal (CMC) osteoarthritis.The pinch grasp is commonly used by the dental hygienist while holding the dental mirror in the non-dominant hand.In response to this concern, manufacturers are redesigning dental mirror handles. The value of these re-designedproducts is based solely on anecdotal evidence. To date, minimal research has been done to examine the non-dominantmirror hand. The purpose of this study was to objectively evaluate dental mirror handle design using surfaceelectromyography (sEMG) to compare muscle activity associated with grasping the mirror.

Methods. This randomized controlled clinical trial utilized a two-by-two repeated measures statistical design. Data wascollected on a convenience sample of 19 (N=19) healthy dental hygiene students in their last year of study. Data collectionwas divided into two phases to maintain a balanced study. The independent variables in phase I were diameter andweight. The independent variables in phase II were weight and padding. Muscle activity was measured while graspingvarious dental hygiene mirrors in 30-second increments using sEMG. Following data collection subjects designatedwhich mirror felt most and least comfortable to compare subjective data with objective data.

Results. Three statistically significant results occurred. In phase II, padding (p=.01) demonstrated the largest reductionof muscle activity in the flexor pollicis brevis, by decreasing mean muscle activity by 3.7 μv. The interaction of diameterand weight (p=.01) in phase I reduced the mean muscle activity in the extensor digitorum by .8 μV and weight (p=.02)in phase II decreased the muscle activity in the extensor digitorum by .62 μV. Self-reports of comfort reported by thesubjects in this study were not consistent with the measurements of muscle activity using sEMG.

Conclusion. Ergonomic adaptations to dental hygiene mirror handles were associated with increases and decreases inmuscle activity. The clinical impact of this is amplified as force is exerted. Furthermore, it may be possible to reduceWMSDs for dental hygienists by using instrument designs during the workday. Self-reports of comfort by the subjectsin this study did not calibrate with the measurements of muscle activity using sEMG. Additional research is needed tofurther isolate the external variables of the study and to determine what actual reduction in muscle activity is significantfor maintaining musculoskeletal health.

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Keywords: musculoskeletal disorders, ergonomics, instrumentation, mirrors, dental hygiene

Introduction

The occurrence of work-related musculoskeletal disorders (WMSDs) in dental hygiene is an occupational concern.Lalumandier and McPhee estimated that 75% of dental hygienists experience hand problems and 56% have classic symptoms

of carpal tunnel syndrome (CTS).1 Data from the Bureau of Labor and Statistics and the US Department of Labor2 revealed

findings consistent with these. Numerous studies1-6 estimate the prevalence of this problem; however, minimal researchexists about the response and interaction of muscles when integrating ergonomic solutions.

WMSDs result in a loss of income, increase in medical expenses, increase in workman's compensation claims, and oftenresult in higher levels of difficulty completing daily tasks. They frequently require days off work, permanently decreasingthe number of days worked, or ultimately a change in career. As a result of findings such as these, prevention ofmusculoskeletal disorders has become a priority for dental hygienists. Many ergonomic devices have been developed andmarketed to the dental community to increase the longevity of dental hygiene careers. The value of these devices is largely

based on practitioner perception by self-reports and focus groups. Spielholz et al8 evaluated three common methods ofergonomic assessment simultaneously: self report, video analyses, and direct measurement using indwelling EMG.Inter-method comparisons between extreme posture, repetition, and force and movement velocity were assessed in 18subjects while processing tree seedlings. Self-reports were the least precise method of measurement when examining

musculoskeletal disorders. The authors concluded that grip force was best quantified by direct measurement using EMG8

Common workplace risk factors contributing to WMSDs is the use of the pinch grasp to hold the instrument while applyingpressing with the finger tips. Studies using physiological measurements noted increased pressure within the carpal tunnel

when a pinch grasp was used when applying pressure9,10 Biomechanical model predictions and tissue studies of exertion

involving pinch grasp demonstrated an increase in the finger flexor tendons11 when pressure was applied. Static biomechanical

models developed at Mayo Clinic12 and at University of Michigan13 have been used to estimate tension in the finger flexortendons during various work tasks. Results concluded that when a normal load is applied to the palmer side of the fingerswhile pinching, mechanical movements are created at the wrist and finger joints. The tensile force to oppose these movements

is much higher than the normal force acting on the fingers when normal force is exerted with only the finger tips.12,13 Pinchgrasp is used for both the mirror hand and the scaling hand. It has been calculated that one pound of pinch between the

thumb and index finger will produce six-to-nine pounds of pressure at the basal joint of the thumb.14 In order to minimizethe effect of the pinch grasp and to create a neutral position, it is recommended that dental instruments and dental mirror

handles have a large diameter, be lightweight, and be padded.15,16

he current literature provides only anecdotal reports that study the effectiveness of diameter, weight, and padding of handleson reducing WMSDs. The purpose of this study was to use sEMG to objectively compare muscle activity associated withcommon structural differences in dental hygiene mirrors while applying simulated dental hygiene procedures. Furthermore,the intention of this study was to allow investigators to examine the interaction of three muscles in the hand and forearmwhen the pinch grasp is used. Phase I involved testing the effects of diameter and weight. Phase II involved testing theeffects of weight and padding.

Review of the Literature

Work-related musculoskeletal disorders (WMSDs) can be acute and/or chronic, and are often a consequence of practicingclinical dental hygiene over time. The most frequently reported altered sensations include pain, tingling, and numbness

in the hands due to the physical stress of performing dental hygiene procedures.17 Reported hand problems, such as carpal

tunnel syndrome (CTS), are consistently higher in the dental hygiene population than in the general population.1-6



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Instrumentation affects a large portion of the modifiable WMSD risk factors. Problems associated with instrumentationinclude: forceful exertions, repetition, small diameter instrument handles, flexion and extension of wrists, pinch forces,

static loading of the fingers and hands, awkward hand postures, and other prehensile motions.15, 18,19 Intervention methodsinclude alternating instrument handle sizes, using instruments with larger diameter handles, using lightweight instruments,and using instruments with rubber coating or padding.

There is a distinct difference between the instrumentation techniques of the scaling hand and the mirror hand. Thenon-dominant hand of the dental hygienist is used for holding the mirror to gain better field visualization and for retractingthe tongue and cheek. Unlike the dominant hand, which performs multiple tasks in a variety of positions to complete thescaling procedures, the non-dominant hand remains in a static position and often requires a forceful grip in order to retract

the tongue and cheek throughout most of the dental hygiene appointment,15 which results in decreased circulation of blood

and oxygen and increases the risk of developing a WMSD.19 To date, no research has addressed this problem.

In a descriptive study by Horstman15 dental hygienists were videotaped and observed during a normal workday. Usingtime and motion analyses, the investigators concluded that the non-dominant hand was in a static posture of wrist flexion

while holding the patient's mouth open, and that it did not engage in wrist flexion and extension.15 In an epidemiologicalstudy using indwelling electromyography (EMG) to examine female dentists performing authentic dental work, Akkesonet al documented more static work in the mirror hand than in the working hand. A combination of extreme palmer flexion

and ulnar deviation in the mirror hand was also noted.19

Experimental and epidemiological research acknowledges the origin of a WMSD as multifactorial.20 A conceptual frameworkfor developing a WMSD has been completed by the National Research Council. In this model, the work environment,organizational factors, and social context are influenced by physical and psychological factors as well as non-work-related

activities.20

Work environment preventive strategies for all upper extremity disorders are similar and suggest creating neutral

environments for the hand, wrist, and thumbs.9, 21, 22 In the landmark study, "The Biocentric Technique: A Guide to Avoiding

Occupational Pain," Meador22 defines a neutral wrist position as the "forearm and hand are in the same horizontal plane."22

He advocates neutral positioning during dental hygiene instrumentation and shifting the workload of the muscles from the

small muscle groups to the large muscle groups.22

The objective of ergonomics is to fit the job to the worker.17 Ergonomic experts in the dental field have maderecommendations for instrumentation modification and selection. These recommendations include decreasing hand forcesduring instrumentation and improving wrist posture18 Suggested instrument variations include increasing the diameter,choosing instruments that are lightweight and balanced, padding the instruments, adapting the shape of the handle and

texture, and varying the sizes.17,23, 24

The utilization of surface electromyography (sEMG) allows the observer to objectively calculate the energy of the muscles.It is safe, easy, noninvasive, and frequently used to evaluate muscle responses to stimuli. When utilizing multiple sensors,

it is possible to differentiate how different aspects of the muscles accomplish various tasks.25 The basis of the sEMG signalis motor unit action potential. This is measured in microvolts (μv). At rest, this measurement is usually around 2 μv. At

work, the muscles begin to contract and the measurement can increase up to approximately 200 μv.25

A common limitation of sEMG is the possibility of crosstalk error, which makes isolating the sEMG recordings to a specific

muscle difficult.25, 26 Utilization of sEMG requires calibration of equipment and analyses and knowledge of muscle anatomy

to prevent crosstalk error.26 Another shortcoming of sEMG is the complexity of the anatomy being studied. The motorneuron pool is comprised of signals from the brain, joints, and other muscles. Nerves transmit these signals. Neurotransmitters

and biochemicals can affect the signal.27 Basmajian and DeLuca27 suggested the sEMG signal indicates the status of themuscle and the status of the nervous system around the muscle.



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To date, no empirical evidence exists to support that instrument modification and selection recommendations will decrease

the occurrence of WMSDs. Numerous studies have suggested the need of further research.8,15,19,23,24 Results of a study by

Spielholz et al indicated that self-reports were the least precise method of measurement.8 Quantification by direct

measurement, such as that of sEMG, would more accurately measure grip forces8, 24 and allow dental hygienists to makemore informed decisions. It has been recommended that quantification needs to be evaluated in both the scaling hand and

the mirror hand.19 A non-subjective approach to data collection is necessary in order to accurately assess the ergonomiceffect of dental hygiene products. The sEMG technique allows the observer to view the muscle at rest and at work and toobjectively quantify the energy of the muscle. When utilizing multiple sensors, it is possible to differentiate how differentaspects of the muscles accomplish various tasks, and how the muscles interact with each other (25).

Statement of the Problem

The purpose of this study was to use sEM G for comparison of muscle activity associated with structural differences indental mirrors when applying simulated dental hygiene positioning. Phase I involved testing the following null hypotheses:

The diameter of dental mirror handles will produce no significant differences in muscle activity when applying simulateddental hygiene procedures.

The weight of dental mirrors will produce no significant differences in muscle activity when applying simulated dentalhygiene procedures.

The interaction effect of diameter and weight will produce no significant differences in muscle activity when applyingsimulated dental hygiene procedures.

Phase II involved testing the following null hypotheses:

1. The weight of dental mirrors will produce no significant differences in muscle activity when applying simulated dentalhygiene procedures.

2. The padding of dental mirror handles will produce no significant differences in muscle activity when applying simulateddental hygiene procedures.

3. The interaction effect of weight and padding will produce no significant differences in muscle activity when applyingsimulated dental hygiene procedures.

Material and Methods

The Sample Power (version 2.0) program (SPSS, Inc., Chicago, IL) was used to estimate sample size. Data (means andstandard deviations) from a pilot study were used to estimate effect size, alpha was set to 0.05, and power was set to 0.80.After entering these data into the program, we determined that a sample size of 10 subjects would provide sufficient powerto detect statistically significant differences in electromyography (EMG) activity while gripping mirror handles of differentsizes and cushioning.

The target population for the study comprised of 28 (N=28) female dental hygiene students in their final semester of studyat the University of Missouri-Kansas City School of Dentistry. A convenience sample of nineteen (N=19) studentsvolunteered to participate and met the inclusion criteria. Two students chose to participate but did not meet the inclusioncriteria to participate. Seven students were not interested in participating.

Inclusion criteria included no significant history or evidence of musculoskeletal disorders within the last 30 days. The

musculoskeletal disorder (MSD) criteria used by Lalumandier and McPhee1 were adopted as inclusion criteria. Thisinformation was obtained through completion of the subject assessment form. Subjects reporting a diagnosis of carpaltunnel syndrome (CTS), history of hand surgery, or answering yes to three or more of the symptoms of past MSDs on the



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subject assessment form were excluded from the study. This was planned to control for external variables influencing theoutcomes.

Demographics, medical conditions frequently related to the development of CTS, and anthropometric characteristics werealso obtained to describe each subject. The same subjects participated in both phase I and phase II. Table I displays themeans (± SD) and the range of demographics and relevant characteristics of the sample with respect to musculoskeletalfactors. Overall this was a very homogenous sample. The sample exhibited a wide distribution of non-modifiable riskfactors such as ages and weights; however, length, breadth, grip diameters, and grip strengths of the sample were all verysimilar. Nine of the subjects had prior dental experience and eight subjects reported one or two symptoms of MSDs withinthe last 30 days.

All subjects gave informed consent to participate in the study and signed the appropriate forms. Confidentiality wasprotected by assigning each subject a number. This study was approved by the Adult Social Science Institutional ReviewBoard at the University of Missouri-Kansas City.

The design of this study for phase I and phase II was a two-factor, repeated measures statistical design. The within-subjectapproach examined the relationship of dental mirror handle diameter, weight, and padding as it related to muscle activityduring simulated dental hygiene positions. The blue arrow brackets in Figure 1 display the mirror handles used to collectdata when evaluating the independent variables, diameter and weight, during phase I of the study. The red arrow bracketsin Figure 1 display the mirror handles used to collect data when evaluating the independent variables, weight and padding,during phase II of the study. This was necessary to keep the design balanced due to the inability to place padding on thelarge diameter mirror handles. Data was collected in two phases over a period of 30 days. A minimum of 24 hours of restwas required between collection of phase I and phase II data.



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For each phase, under identical testing conditions, participants were asked to grasp mirror handles two times, accordingto the mirror sequence assignment, in order to assess consistency of grasping technique within each individual. The secondround of testing occurred in the reverse order of the first. Motor unit action potential (MUAP), commonly referred to asmuscle activity, was measured in μV, using the Noraxon® sEMG apparatus. Reliability was assessed using Pearson productmoment correlation coefficient, significant at the 0.01 level (2-tailed), for each mirror handle within each muscle group.The coefficients for phase I ranged from 0.69 to 0.98. The coefficients for phase II ranged from 0.63 to 0.96. Based onthe internal consistency of the sEMG readings, a mean score was completed for each mirror within each muscle group foreach subject. The average score was computed to represent a single measure of muscle activity. This mean score was usedfor statistical analyses.

Dental hygiene positioning was reproduced through a simulated dental hygiene clinic. A dentoform mounted on a polewas placed in a standard patient chair in a supine position. The clinician sat on a standard operator stool.

Miniature, circular Noraxon® 2 cm diameter, dual silver-chloride surface electrodes were used to collect sEMG data from

each muscle group. Figure 2 displays the bipolar sensor configuration recommended by Hermens et al.26 A single, circularNoraxon®, 4 cm diameter, surface electrode was placed on the dorsal side of the wrist and used as a ground. All electrodeswere pre-gelled. All surface sites were cleansed with alcohol on gauze pads prior to electrode placement.



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The electrodes were connected to electromyography (EMG) Module MyoSystem1200. The fullwave rectified outputsfrom the modules were fed into a Toshiba® laptop satellite computer. Figure 3 displays the three channels used to delineateMUAP (muscle activity) between each of the three muscles being measured. The computer interface converted the analoguesignals to digital form. The operation of the interface was controlled by MyoResearch XP software.



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Surface electrodes were placed on the extensor digitorum, flexor pollicis brevis, and flexor digitorum superficialis by anexperienced, licensed occupational therapist to determine correct muscle identification and electrode placement. Anoccupational therapist was chosen for muscle identification and electrode placement due to their skilled background of

human anatomy and neuroanatomy.28 The same occupational therapist was used throughout the data collection ensureintra-rater reliability. All surface electrodes were placed according to sEMG sensors and sensor placement recommendations

developed at the European concerted action SENIAM (surface EMG for a non-invasive assessment of muscles).26

Surface electrodes were placed on the extensor digitorum muscle group by palpating the middle of the forearm approximatelythree quarters of the distance between the elbow and the wrist while having the subject extend her fingers. The inter-electrodedistance was 2 cm. The sensors were placed in the distal part of this muscle between the innervation zone and the end

zone. The orientation of the electrodes was parallel to the muscle fibers of the extensor digitorium 26 Once electrodes wereplaced, subjects were requested to extend fingers with resistance in order to ascertain the correct muscle was being

evaluated.25

Surface electrodes were placed on the flexor pollicis brevis muscle group by palpating the medial aspect of the thenareminence while the subject flexed her thumb. The sensors were placed in the distal part of this muscle between theinnervation zone and the end zone. The orientation of the electrodes was parallel to the muscle fibers of the flexor pollicis

brevis muscle group. The inter-electrode distance was 2 cm.26 Once electrodes were placed, subjects were requested to

abduct their thumb in order to ascertain that the correct muscle was being evaluated.25

Surface electrodes were placed on the flexor digitorum superficialis muscle group by palpating approximately three quartersof the distance from the elbow to the wrist on the ventral side of the middle of the forearm while having the wrist supported.The inter-electrode distance was 2 cm. The sensors were placed in the distal part of this muscle between the innervationzone and the end zone. The orientation of the electrodes was parallel to the muscle fibers of the flexor pollicis brevis

muscle.26 Once electrodes were placed, subjects were requested to make a fist and flex their wrist in order to ascertain that

the correct muscle was being evaluated.25

Signals from the sEMG apparatus that appear equally, and on two electrode conductors at the same time, are consideredcommon mode disturbance, commonly referred to as noise. Noise is seen with respect to a system's ground reference

point.25 A single reference electrode was placed on the dorsal side of the wrist where the tissue was electrically inactive.

This minimized risk for common mode disturbance.26 The three muscle groups were studied simultaneously.

A predetermined, stratified mirror sequence was placed in separate envelopes and randomly assigned to each subject forboth phases of the study. This ensured mirror order was balanced. The envelope was given to the investigator at the timeof data collection.

Subjects were placed in a neutral operator position as defined by Nield.29 Subjects had their arms at waist level, feet flaton the floor, thighs parallel to the floor, back at a 100-degree angle to the chair, head erect, and body evenly distributed.The typodont was open in a chin-up position. Subjects were required to sit in the 12:00 operator position and instructedto look down into the typodont's mouth as displayed in Figure 4. Subjects used a modified pen grasp in a gloved hand topinch grasp the dental mirror while examining the lingual surface of the typodont model's maxillary anterior teeth in themirrors reflection. Subjects were instructed to hold this posture for 30 seconds in order to create a static environment. Thesubjects had a minimum of 30 seconds of rest between each testing. Figure 5 displays subject stretching and changingpositions in order to reach the required minimum resting threshold of 2.0 μV preceding taking measurements. The principleinvestigator instructed the subjects to stop and resume the pinching task as indicated by the sEMG timer and minimumthreshold measurements.



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Quantitative data obtained from the MyoResearch XP software were coded and entered into the Statistical Package of

Social Science (SPSS) 12.0. RM ANOVA (p≤ 0.05) and appropriate descriptive statistics including frequency distributionsand central tendencies were computed for both main and interaction effects. Two factors were measured in phase I (factor1= thin and thick, factor 2=heavy and light). Two factors were measured in phase II (factor 1= heavy and light, factor2=unpadded and padded). An estimation of effect size was determined by calculating partial eta squared, a standardized

technique for this purpose.30



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Results

Table II displays mean (± SD) values of muscle activity for the three muscles under each condition for phase I. Repeated

measures (RM) ANOVA (p≤ 0.05) was applied to evaluate main and interaction effects. Individual means are reportedfor each mirror handle an the marginal means are reported to help interpret the main effects. Results show a statistically

significant (p=.01, η2=0.29) interaction of diameter and weight affecting muscle activity in the extensor digitorum. This

result is further supported by the partial eta-squared statistically associated with this effect.30 A greater level of muscleactivity was present with the thin plastic handle, and the opposite effect occurred with the thick plastic handle. The main

effects of diameter (p=.14, η2=.12) and weight (p=.58, η2=.02) were not determined to be statistically significant; however,

the partial eta-squared indicates diameter had a low to moderate effect on muscle load during testing activities.30

For the flexor pollicis brevis, the interaction effect of diameter and weight (p=.53, ?2=.02), and the main effects of diameter

(p=.36, η22=.05) and weight (p=.17, η2=.10) were not statistically significant. For the flexor digitorum superficialis, the

interaction effect of diameter and weight (p=.48, η2=.03), and the main effects of diameter (p=.53, η2=.02) and weight

(p=.10, η2=.14), were not statistically significant.

Due to the following phase I results, we reject the following null hypothesis: There will be no interaction effect of diameterand weight that will produce significant differences in muscle activity when applying simulated dental hygiene procedures.We favor the following hypothesis: The interaction of diameter and weight will produce significant differences in muscleactivity when applying simulated dental hygiene procedures. We failed to reject the following null hypothesis: The diameterof dental mirror handles will produce no significant differences in muscle activity when applying simulated dental hygieneprocedures and the weight of dental mirrors will produce no significant differences in muscle activity when applyingsimulated dental hygiene procedures.

After phase I testing, the subjects delineated which mirror handle provided the most comfort and the least comfort. TableIII displays the percentage of mirror preferences delineated by each subject. Individual's subjective assessment of comfortwas also compared to their muscle activity to evaluate accuracy of each subject's preference. Forty-two percent of thesubjects accurately identified which mirror was most comfortable within the extensor digitorum and the flexor digitorumsuperficialis. Thirty-two percent of the subjects accurately identified which mirror was most comfortable within the flexorpollicis brevis. Eighteen percent of the subjects accurately identified which mirror was least comfortable within the extensordigitorum. Thirty-two percent of the subjects accurately identified which mirror was least comfortable within the flexorpollicis brevis. Twenty-six percent of the subjects accurately identified which mirror was least comfortable within theflexor digitorum superficialis.



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Table IV displays mean (± SD) values for electromyography for the three muscles under each condition for phase II.

Repeated measures (RM) ANOVA (p≤ 0.05) was applied to evaluate main and interaction effects. Individual means arereported for each mirror handle and the marginal means are reported to help interpret the main effects. Results show that

weight (p=.02, η2=0.27) had a statistically significant effect on muscle activity in the extensor digitorum with an associated

partial eta-squared supporting this conclusion.30 The main effect of padding (p=.60, η2=.02), and the interaction effect of

weight and padding (p=.39, η2=.04) were not significant.

In the flexor pollicis brevis, results illustrate the main effect of padding had a statistically significant effect (p=.01, η2=.30)

on muscle activity while grasping mirror handles. Results for the main effect of weight (p=.34, η2=.05), and the interaction

effect of weight and padding (p=.22, η2=.08) were not statistically significant.

The flexor digitorum superficialis had an interaction effect of diameter and weight (p=.53, η2=.02) that was not statistically

significant. The main effects of weight (p=.90, η2=.001) and padding (p=.88, η2=.001) were not statistically significant.



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Due to the following phase II results, we reject the following null hypotheses: The weight of dental mirrors will produceno significant differences in muscle activity when applying simulated dental hygiene procedures and the padding of dentalmirror handles will produce no significant differences in muscle activity when applying simulated dental hygiene procedures.We favor the following hypotheses: The weight of dental mirrors will produce significant differences in muscle activitywhen applying simulated dental hygiene procedures and the padding of dental mirror handles will produce significantdifferences in muscle activity when applying simulated dental hygiene procedures. We failed to reject the following nullhypothesis: There will be no interaction effect of weight and padding that will produce significant differences in muscleactivity when applying simulated dental hygiene procedures.

After phase II testing, the subjects delineated which mirror handle provided the most comfort and the least comfort. TableV displays the percentage of preferences delineated by each subject. Individual's subjective assessment of comfort wasalso compared to their muscle activity to evaluate accuracy of each subject's preference. Twenty-one percent of the subjectsaccurately identified which mirror was most comfortable within the extensor digitorum and the flexor pollicis brevis.Thirty-two percent of the subjects accurately identified which mirror was most comfortable within the flexor digitorumsuperficialis. Five percent of the subjects accurately identified which mirror was least comfortable within the extensordigitorum. Sixteen percent of the subjects accurately identified which mirror was least comfortable within the flexor pollicisbrevis. Twenty-six percent of the subjects accurately identified which mirror was least comfortable within the flexordigitorum superficialis.

Discussion

Clinical Relevance

Unfortunately, research is not available that delineates how much muscle activity equates to the development of awork-related musculoskeletal disorder (WMSD), so the direct application of the data gathered in this study is narrow. Thelargest statistically significant reduction of muscle activity occurred during phase II of this study, in one of the largestmuscles of the thumb, the flexor pollicis brevis. Padding reduced mean muscle activity by 3.7 μv. In phase I, the interactionof diameter and weight decreased the muscle activity in the extensor digitorum by 1.3 μV and in phase II, weight decreasedthe muscle activity in the extensor digitorum by .62 μV. Research indicates that muscle activity ranges from a resting state



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of 0-2 μV, and can reach as high as 200 μV. 25 It is difficult to ascertain if these rather small decreases in muscle activitywould result in promoting musculoskeletal health.

When comparing the subjective data to the objective data in phase I, 68% of the subjects surmised the thick plastic mirrorhandles were the most comfortable. This is consistent with the mean muscle activity and the statistically significantinteraction of diameter and weight within the extensor digitorum. Seventy-four percent of the subjects identified the thinmetal mirrors were least comfortable. This calibrated with having the highest mean muscle activity in the extensor digitorum,however, it is inconsistent with the findings of the other muscle groups. Seventy-four percent of the subjects surmised theplastic handles were the most comfortable. Fifty-three percent of the subjects identified metal handles were the leastcomfortable. This is consistent with the statistically significant main effects of weight within the extensor digitorum. Themirror preferences are also consistent with the mean muscle activity in the extensor digitorum, wherein the padded plastichandle required the least amount of muscle activity; however, it is inconsistent within the other muscle groups. Eighty-five percent of the subjects surmised padded mirror handles were the most comfortable. Seventy-four percent of thesubjects identified non-padded mirror handles were the least comfortable. This is consistent with the statistically significantmain effect of padding in the flexor pollicis brevis. Within the flexor pollicis brevis, the padded metal handle required theleast amount of muscle activity and the non-padded metal handle required the most muscle activity; however, it is inconsistentwithin the other muscle groups.

When comparing the overall subjective data to the statistically significant objective data, it appears that subjects had agood sense of what instrument required the least amount of work (μv). This was not true for the effects that were notstatistically significant. When comparing each individual's mirror preferences with her muscle activity, less accuracy

occurred, supporting the results of Spielholz et al; self-reports are the least precise measurement for evaluating ergonomics.8

The self-reports by the subjects in this study were less precise than the measurements of muscle activity using surfaceelectromyography (sEMG) when evaluating comfort of mirror handles.

Previous studies demonstrated an increase in intracarpal tunnel pressure9, 10 and an increase in tension forces in the finger

flexor tendons11 when force is exerted. Results from evaluating static and biomechanical models concluded the tendonforce is a function of hand size, position, and load. Opposition of movements in the finger flexor tendons is much higher

than that of normal force acting on the fingers when normal force is exerted with only the finger tips.12, 13 Studies by Hagg

et al31 supported that different dose definitions of muscle activity should be applied depending on the tissue at risk. He

also stated that the overexertion risk increases more than proportionally with increasing mechanical load.31 Dental hygienistspinch grasp mirrors several hours of the workday, often with pressure due to retracting the cheek and tongue. Whenapplying the above research to the task of performing dental hygiene procedures, one might assume that as force is exertedduring gripping and pinching activities, the magnitude of tensile strain in the tendons will increase, which augments therisk of muscle overexertion. Consequently, when considering force and the magnitude of tensile strain, the impact of evena small reduction of muscle activity may be significant in the prevention of WMSDs.

Recommendations for ergonomic instrumentation focus on alternating instruments and using a variety of handle diameters

and weights within each instrument kit.17, 21, 23 Data from this study support this recommendation. The muscle activityresponse between the best and worst handle for each muscle group was of interest. Sixty-eight percent of the subjects inphase one and fifty-eight percent of the subjects in phase II had at least one mirror handle that was best for one musclegroup and worst for a different muscle group at the same time. One could conclude that alternating instrument handlesthroughout each appointment would allow for varying muscles to work and rest throughout each appointment, which couldimprove musculoskeletal health.

Upon examining the data of each individual, it is notable that due to the complexity of the muscles and nervous system,the muscle response to the external load (mirror handles) was different for each subject. Some subjects had a decrease inmuscle activity with lightweight handles while others had an increase in muscle activity associated with lightweighthandles. This was also true for diameter and padding. Optimal handle trends were suggested by the main and interactioneffects; however, there was no "one size fits all" handle. Tactile cues available at the end of finger movements provide a

powerful stimulus for the control of the finger muscles.32 In a study that evaluated temporal synergies of hand movement



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and sensory cues, Santello et al found that tactile cues influenced hand postures as the hand contacted objects.33 Weightand texture are external variables that provide tactile cues and could affect muscle activity. This may perhaps explain whylightweight instruments decreased muscle activity in many of the subjects; however, in a limited number of subjects itcaused an increase in muscle activity. A variety of handle textures are available to clinicians; however, this variable wasnot controlled for or measured in the present study. This needs to be an additional parameter proscribed in future studies.

Limitations

Due to prescribed manufacturer features (set diameters and weights); it was not possible to conduct a fully balanced design.The Acushy® grip, used to pad instrument handles, was not compatible with the wide diameter instrument handles. Thisis why it was necessary to design the study to collect data in two phases. Although measures were taken to totally balancethe study, they were not fully accomplished.

The pilot test used for power analysis was completed on three experienced dental hygiene faculty members. The subjects(N=19) used in this study were senior dental hygiene students. Overall, the subjects used in this study did not reflect thecharacteristics of the subjects in thepilot test. Using this population allowed for greater control of the external variablesthat could affect the study results, however, it greatly limited the variability of the data. Over half of the subjects used inthe study were inexperienced in the dental field, which we hypothesize may have contaminated the power analysis. Thepower of the study was impaired by the predetermined sample not being large enough.

Hagg et al31 stated, "The indication of muscular fatigue in occupational field applications comprises a general problemsince both, the EMG amplitude as well as the spectrum, depend not only upon the fatigue state but also on the producedforce." Force was not measured in this study, which makes comparing phase I and phase II data problematic because wecannot ascertain that equal force was used from one phase to the next. Data from each phase must be looked at as individualentities.

General Remarks

This exploratory study is the first randomized controlled trial exploring empirical evidence to support instrument modificationchoices in dental hygiene mirrors. While trends in muscle activity were observed under varying instrument characteristics,only some were statistically significant. Further research is necessary to ascertain the results.

This study had a homogenous anthropometry of hand demographics. The mean female hand breadth is 92 mm (± 6 mm).34

This was very comparable to our sample. Future ergonomic studies examining muscle activity should include examiningdiameter, weight, and padding on a larger, more diverse sample by which additional analyses to determine what roleanthropometrics of the hand play in muscle activity should be explored. It is also of interest to explore the effects of load(resistance), such as that while retracting the cheek or tongue, while grasping dental hygiene mirrors. Examining muscleactivity while scaling calculus with any of the above variables would also be beneficial. Ultimately, the utilization ofbiomechanical models and temporal neural networks to map and predict the interaction of muscle activity in a cross-sectionalsample of dental hygienists is necessary to completely understand the relationships between muscles and external variables.

Conclusion

Altering the weight, diameter, and padding of dental hygiene instrument handles appears to have an affect on muscleactivity; however, further research is needed to determine optimal handle design. Ergonomic adaptations to dental hygieneinstrument handles seem to impact muscle activity; it may be possible to reduce work-related musculoskeletal disordersfor dental hygienists by altering instrument designs during the workday. Self-reports of comfort by the subjects calibratedwell with the statistically significant effects; however, they did not calibrate well with non-statistically significant effects.Each individual's subjective assessment of comfort did not parallel the amount of muscle activity objectively measuredusing surface electromyography (sEMG). The individual sEMG data suggests instrument handles should be tailored tobest fit each individual. Ultimately, a biomechanical means of predicting muscle activity would allow for better selectionof ergonomically focused instruments.



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Acknowledgements

The authors wish to thank The Rinehart Foundation for funding this project and Acushy Product Company, AmericanEagle, Hu-Friedy, Nordent, Premier, and Paradise Dental Technologies for donating products to be evaluated.

Notes

Correspondence to: Melanie Simmer-Beck at [email protected]

References1. Lalumandier JA, McPhee SD. revalence and risk factors of hand problems and carpal tunnel syndrome among dental hygienists

. J Dent Hyg. 2001;75(2): 130-34.2. Bureau of Labor Statistics, US Department of Labor,. Special Report. Washington (DC): US Department of Labor; 2004. June28.3. Anton D, Rosecrane J, Merlino L, Cook T. Prevalence of musculoskeletal symptoms and carpal tunnel syndrome among dental

hygienists. Am J Ind Med. 2002. Sept;43(2): 248-57.4. Shenkar O, Mann J, Shevach A, Ever-Hadani P, Weiss P. Prevalence and risk factors of upper extremity cumulative trauma

disorder in dental hygienists . Work. 1998. Nov;11(3): 263-75.5. Rice VJ, Nindl B, Pentikis JS. Dental workers, musculoskeletal cumulative trauma, and carpal tunnel syndrome: who is at risk?

a pilot study. Int J Occup Saf and Ergon. 1996;2(3): 218-33.6. Liss GM, Jesin E, Kusiak RA, White P. Musculoskeletal problems among Ontario dental hygienists. Am J Ind Med. 1995.

Oct;28(4): 521-40.7. Morse TF, Dillon C, Warren N, Levenstein C, Warren A. The economic and social consequences of work-related musculoskeletal

disorders: the Connecticut upper-extremity surveillance project (CUSP). Int J Occup Environ Health.. 1998. Oct-Dec;4(4): 209-16.8. Spielholz P, Silverstein B, Morgan M, Checkoway H, Kaufman J. Comparison of self-report, video observation, and direct

measurement methods for upper extremity musculoskeletal disorder physical risk factors. Ergonomics. 2001. May;44(66): 588-613.9. Rempel D, Keir PJ, Smutz WP, Hargens A. Effects of static fingertip loading on carpal tunnel pressure. J Orthop Res. 1997.

May;15(3): 422-6.10. Seradge H, Jia YC, Owens W. In vivo measurement of carpal tunnel pressure in the functioning hand. J Hand Surg [Am]. 1995.

Sep;20(5): 855-59.11. Armstong TJ. Circulatory and local muscle responses to static manual work [PhD dissertation]. 1976. Ann Arbor (MI). The

University of Michigan.12. Chao EY, Opegrand JD, Axmear FE. Three-dimensional force analysis of finger joints in selected isometric hand functions. J

Biomech. 1976;9(6): 387-96.13. Armstong TJ, Chaffin DB. Some biomechanical aspects of the carpal tunnel. J Biomech. 1979;12(7): 567-70.14. Thumb arthritis [homepage on the Internet]. Jacksonville, FL: Southeastern Hand Center; [cited 2004 June 28]. Available from:

www.handsurgery.com/arthritis.html.15. Horstman SW, Horstman BC, Horstman FS. Ergonomic risk factors associated with the practice of dental hygiene: a preliminary

study . Prof Safety. 1997 . Apr;42: 49-53.16. Stentz TL, Riley MW, Harn SA, Sposato RC, Stockstill J, Harn JA. Upper extremity altered sensations in dental hygienists. Int

J Ind Ergon. 1994. Apr;13(2): 107-12.17. Michalak-Turcotte C. Controlling dental hygiene work-related musculoskeletal disorders: the ergonomic process. J Dent Hyg.

2000. Winter;74(1): 41-48.18. Sanders MA, Turcotte CM. Strategies to reduce work-related musculoskeletal disorders in dental hygienists: two case studies. J

Hand Ther. 2002. Oct-Dec;15(4): 363-74.19. Akesson I, Hansson GA, Balogh I, Moritz U, Skerfving S. Quantifying work load in neck, shoulders and wrists in female dentists

. Int Arch Occup Environ Health. 1997;69(6): 461-74.20. National Research Council. Work related musculoskeletal disorders: a review of the evidence. Washington (DC): National

Academy Press; 1998. 1- 5.21. Winzeler S, Rosenstein BD. Occupational injury and illness of the thumb. causes and solutions. AAOHNJ. 1996 . Oct;44(10):

487-92.22. Meador H. The biocentric technique: A guide to avoiding occupational pain. J Dent Hyg . 1993. Jan;67(1): 38-51.23. Liskiewicz ST, Kerschbaum WE. Cummulative trauma disorders: an ergonomic approach for prevention . J Dent Hyg. 1997.

Summer;71(4): 162-7.



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24. van der Beek AJ, Frings-Dresen MH. Assessment of mechanical exposure in ergonomic epidemiology. Occup Environ Med.1998. May;55(5): 291-9.

25. Cram JR, Kasman GS, Holtz J. Introduction to surface electromyography. Gaithersburg (MD): Aspen Publishing; 1998. 5-7,46-57, 316-29.

26. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placementprocedures. J Electromyogr Kinesiol. 2000. Oct;10(5): 361-74.

27. Basmajian JV, DeLuca CJ. Butler J. Muscles alive: their functions revealed by electromyography. (5thed). Baltimore (MD):Williams & Wilkins; 1985. 125- 29, 168- 86.

28. Consumer Information [homepage on the Internet]. Bethesda (MD): The American Occupational Therapy Association Inc; [cited200 Feb 28]. Available from: h http://www.aota.org/featured/area6/index.asp.

29. Nield JS. Fundamentals of periodontal instrumentation and advanced root instrumentation . (5thed). Philadelphia (PA): LippincottWilliams & Wilkins; 2004. 14- 21.

30. Kirk RE. Experimental design: procedures for the behavioral sciences. (2nded). Belmont (CA): Brooks/Cole; 1982. 64, 180- 2,444- 5.

31. Hagg GM, Luttmann A, Jager M. Methodologies for evaluating electromyographic field data in ergonomics . J ElectromyogrKinesiol. 2000. Oct;10(5): 301-12.

32. Johannsson RS, Cole KJ. Sensory-motor coordination during grasping and manipulative actions. Curr Opin Neurobiol. 1992.Dec;2(6): 815-23.

33. Santello M, Flanders M, Soechting JF. Patterns of hand motion during grasping and the influence of sensory guideance. J Neurosci.2000. Feb;22(4): 1426-35.

34. Chaffin D, Andersson G. Occupational Ergonomics. Brisbane: John Wiley & Sons; 1984. 366.



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Ethics Instruction in the Dental Hygiene Curriculum

Mark G Kacerik, Renee G Prajer and Cynthia Conrad

Mark G. Kacerik, RDH, MS, is assistant professor, sophomore clinic coordinator, Department of Dental Hygiene; Renee G. Prajer,RDH, MS, is assistant professor and junior clinic coordinator, Department of Dental Hygiene; Cynthia Conrad, PhD, associate professor,Department of Public Management, all at the University of New Haven, West Haven, Connecticut.

Purpose. Dental hygiene ethics is an essential component of the dental hygiene curriculum. The accreditation standardsfor dental hygiene education state that graduates must be competent in applying ethical concepts to the provision and/or

support of oral health care services.1 Although the standards for entry into the profession of dental hygiene emphasizethe importance of ethical reasoning, there is little published research specific to ethics instruction in dental hygieneprograms. The purpose of this study was to assess how ethics is taught in the dental hygiene curriculum.

Methods. A 17-item survey was designed and distributed to 261 accredited dental hygiene programs in the United Statesfor a response rate of 56% (N=147). The survey requested that participants provide information on teaching andevaluation methodologies, didactic and clinical hours of instruction, individuals responsible for providing instruction,and the degree of emphasis placed on ethics and integration of ethical reasoning within the dental hygiene curriculum.

Results. Results of the survey reflect that dental hygiene programs devote a mean of 20.2 hours to teaching dentalhygiene ethics in the didactic component of the curriculum. With regard to the clinical component of the curriculum,63% of respondents indicated that 10 or less hours are devoted to ethics instruction. These results show an increase in

didactic hours of instruction from previous studies where the mean hours of instruction ranged from 7 to 11.7 hours.2

Results showed 64% of respondents offered a separate course in ethics; however, 82% of programs surveyed indicatedthat ethics was incorporated into one or more dental hygiene courses with 98% utilizing dental hygiene faculty toprovide instruction. Most programs utilized a variety of instructional methods to teach ethics with the majority employingclass discussion and lecture (99% and 97% respectively). The type of institution-technical college, community college,four-year university with a dental school, and four-year university without a dental school-had little influence on thedegree of emphasis placed on teaching ethics. Although the number of hours devoted to ethics instruction has increased,43% of respondents indicated that they would like to see more emphasis placed on ethics in the program with whichthey are affiliated.

Conclusion. This study reveals that programs have taken measures to employ a variety of teaching strategies to ensurethat students are competent in applying ethical concepts in the provision of oral health care. However, programscontinue to rely primarily on traditional methods of instruction and evaluation such as lecture, discussion, quizzes,and written assignments. Inferential analysis focusing on the influence of the type of institution, showed that in general,the type of institution has little influence on the level of emphasis placed on teaching ethics in dental hygiene curricula.It is recommended that dental hygiene programs continue to implement and evaluate instructional methods that simulatereal life experiences and emphasize ethical concepts that promote comprehensive oral health care. Future studiesshould investigate the effectiveness of ethics instruction within dental hygiene curricula.

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Keywords: Ethic instruction, curriculum assessment, dental hygiene education, professional responsibility, code of ethics

Introduction

As professionals, dental hygienists have responsibilities to their clients, employers, and the profession. It is essential thatdental hygienists be prepared to make decisions based on ethical reasoning, and for dental hygiene programs to preparethem for this responsibility. How then are dental hygiene programs preparing graduates to practice ethically and makeethical decisions? The purpose of this study was to assess how ethics is being taught in accredited dental hygiene programs.The researchers are hopeful that educators will utilize this information to assist them in program assessment and planning

Review of Literature

"Competencies for Entry into the Profession of Dental Hygiene" identifies the skills that are expected of a dental hygienist

upon entering the profession.3 These competencies are divided into five domains: core competencies, health promotionand disease prevention, community involvement, patient/client care, and professional growth and development. Dentalhygiene programs are responsible for ensuring that graduates demonstrate competency in all of the domains, beginningwith the core competencies, which provide the foundation for all the roles of the dental hygienist. Defined within the core

competencies are the ethics, values, skills, and knowledge that are integral to all aspects of the profession.3

The accreditation standards for dental hygiene education programs state that "[g]raduates must be competent in applying

ethical, legal, and regulatory concepts to the provision and/or support of oral health care services."1 The agency thataccredits dental hygiene educational programs, the American Dental Association's (ADA) Commission on DentalAccreditation (CODA), has identified several general guidelines for programs to demonstrate evidence of compliance inmeeting this standard including: written course documentation in ethics, ethical reasoning and professionalism, evaluation

mechanisms designed to monitor knowledge of performance, and outcomes assessment mechanisms.1

Although the standards for entry into the profession of dental hygiene emphasize the importance of ethical reasoning, thereis little published research specific to the instruction of ethics in dental hygiene programs. A 1982 study on ethics instructionin dental hygiene programs found that although ethics was a component of the curriculum, the hours of instruction and

teaching methods varied considerably among programs.2

In a series of studies conducted on the status of dental ethics instruction, results suggest an increased emphasis in providingethics instruction in dental schools. A 1998 survey of dental schools showed that the number of programs offering at least

one course in dental ethics went from 79% in 1986 to 91% in 1998.4 However, it was revealed that even though there wasan increase in ethics instruction, the total number of credit hours devoted to ethics remained relatively low in comparison

to the overall curriculum.4

Current literature questions the effectiveness of ethics instruction in dental curricula. It has been suggested that teachingethics is different from teaching a student to make ethical decisions as an individual. Some educators believe that one'spersonal ethics stem from an introspective standpoint in order to change one's behavior or beliefs and in order for a

professional to practice ethically.5 Perhaps this is consistent with the notion that ethics education and practicing ethics, asan individual/professional, are not necessarily congruent. Research has indicated that practicing dental hygienists felt thattheir ethical beliefs were developed outside of their educational experience, yet they noted that role models contributed

to their ethical developments.5,6

One concern with regard to teaching ethics is who, based on qualifications, should be responsible for providing the

instruction. Historically in dental hygiene and dental programs, dental hygiene or dental faculty have taught ethics courses.2,6

In a 1982 study by Jong and Heine,2 50% of dental hygiene faculty surveyed indicated that they did not possess adequateknowledge of moral philosophy to select readings or to bring out important theories to deal with moral dilemmas. Although



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it would be ideal to have a dental health care professional with a Ph.D. in philosophy teach the ethics course, this is not arealistic expectation. A more practical approach to ethics instruction would be team-teaching so that colleagues could rely

on each other's area of specialty to supplement the knowledge that they do not have.6

How successful dental hygiene programs have been in providing students with ethics instruction can be assessed by looking

at how dental hygienists deal with ethical dilemmas that they encounter in practice. In a study by Gaston et al,7 practicingdental hygienists were surveyed to determine the types of ethical problems they encountered and the type of instructionthey received in ethical theory. Eighty-six percent of dental hygienists reported that they had formal instruction in ethicaltheory, with 56% receiving this instruction in a separate course, rather than as part of another course. The majority ofrespondents, 61%, reported that the instruction they received had been lecture only; 38% reported havingdiscussion/demonstration instruction. Most of the responding dental hygienists reported that they encountered ethicalproblems that they did not feel prepared to address. From this study, the researchers concluded that there should be a

review of the curriculum with regard to ethics instruction to better prepare dental hygienists for addressing ethical problems.7

An exploratory study conducted by Christie et al8 indicated that the majority of faculty value the importance of developingstudent competence in ethical reasoning and professional responsibility, but find it difficult to evaluate competence in thisdomain. The researchers concluded that faculty need training in assessment of ethical reasoning and the utilization ofdiverse methods of practical evaluation tools such as test cases, case presentations, research projects, and portfolios to

assess students' level of competence in regards to ethics.8 Critical thinking has been advocated as an approach to ethicseducation in the clinical learning environment. Performance assessments such as authentic evaluation can be utilized to

provide students with experiences that mimic real life situations including cases and standardized patients.9,10

Methods

A survey was designed to gather data on instructional methodologies and the degree of emphasis placed on ethical reasoningand professional responsibility within dental hygiene programs. The survey requested that participants respond to questionsregarding their teaching methodologies in ethics, and how many hours of instruction in dental hygiene ethics, both didacticand clinical hours, they included in their curriculum. The 17-item survey consisted of both closed-ended questions andopen-ended questions, as well as a section where participants were asked to evaluate the degree of emphasis placed onethics within the dental hygiene curriculum, from a didactic and clinical perspective, based on the ADHA Code of Ethics

for Dental Hygienists.11 The survey was distributed to faculty within the department and revisions were made to improvethe clarity of survey items in relation to the rating scale used to assess the level of emphasis placed on ethics. A five-pointLikert rating scale was used with (5) indicating a very high level of emphasis and (1) indicating a very low level of emphasis.The survey, a cover letter and a self-addressed, postage paid envelope were mailed to program directors of 261 accrediteddental hygiene programs in the United States. Both the surveys and the return envelopes were coded to identifynon-respondents for a follow-up mailing. Participants were informed that responses to the survey would be confidentialand that surveys were numbered to monitor responses and provide follow-up mailings if necessary. The program directorswere given four weeks to complete the survey. One hundred and forty-seven responses were received, resulting in a 56%response rate. Some surveys had incomplete information and were not appropriate for statistical analysis. As a result, someof the analyses that follow include less than 147 cases. In addition, individuals completing the survey included multipleresponses for items that required a single response, resulting in percentages totaling more than 100%. Although the surveyswere mailed to directors, it is not known if the directors themselves completed the survey instrument, or if it was given tofaculty to complete. The results of the survey were quantified and an Excel database was utilized to obtain descriptivestatistics. The researchers used the same database in inferential analysis using SPSS version 12.



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Results

Descriptive Findings

When asked how ethical concepts are incorporated in the curriculum, the researchers received multiple responses. Of therespondents, 64% indicated that ethics was taught in a separate course, 22% indicated it was incorporated into a dentalhygiene course, 60% indicated that ethics was incorporated into several dental hygiene courses, and 7% indicated "other,"noting that ethics was incorporated throughout the curriculum and modeled by faculty.

The amount of hours devoted to teaching ethics in the didactic portion of the curriculum varied with 41% devoting 11-20hours of instruction and 27% devoting 0-10 hours. A mean of 20.2 hours of didactic instruction is devoted to ethics (Figure1).

With regard to the clinical component of the curriculum, 63% of respondents indicated that 10 or less clinical hours aredevoted to ethics instruction, 11% offer 11-20 hours, 5% offer 21-30 hours, 4% offer 31-40 hours, and 17% offer 41 ormore hours of instruction in the clinical component (n=81 or 55% of respondents). Those that did not respond indicatedit was difficult to calculate the hours devoted to instruction in the clinic setting.

Multiple responses were received from participants when asked who is responsible for teaching ethics. Ninety-eight percentuse dental hygiene faculty to provide instruction, 3% use philosophy faculty, while 5% use dentists, lawyers, and guestsspeakers.

Results indicated that the majority of programs employ multiple strategies for providing ethics instruction. Lecture, classdiscussion, and case scenarios were the most frequently used methods. Other methods include: debates, student portfolios,written assignments, online discussion boards, and guest lecturers. Figure 2 provides percentages of the methods ofinstruction used to teach ethics.



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Programs utilize a variety of reading resources for ethics assignments. Of the respondents, 94% use the American DentalHygienists' Association Code of Ethics for Dental Hygienist as a resource, 73% use current literature, 61% use textbooksthat are required for other dental hygiene classes, and 63% require a separate textbook on dental hygiene ethics. Otherreading resources include state practice acts, videos, state board newsletters, and online resources.

Evaluation systems also vary with the responding programs; 89% of respondents use tests/quizzes and 73% use writtenassignments to evaluate students on ethical concepts. Of the responding programs, 19% reported that no specific testingwas employed. Rather, students are evaluated on their overall behavior/professionalism (Figure 3).

Ninety-two percent of programs surveyed evaluate the students' use of ethical concepts in the clinical setting. Three percentindicated they do not evaluate students in the clinical setting, while others noted they do not provide specific evaluationand/or only address issues if breached.

Survey results show that 60% of the respondents calculate ethical concepts into the students' clinical grade with a weightof 1-10%, 24% calculate ethical concepts into the students' clinical grade with a weight of 11-20%, 6% calculate ethicalconcepts into the students' clinical grade with a weight of 21-30%, 4% calculate ethical concepts into the students' clinical



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grade with a weight of greater than 30%, and 6% do not calculate the use of ethical concepts in to students' grade at all.Figure 4 shows what percentage of ethical concepts is calculated into the students' clinic grade.

When asked, "would you like to see more emphasis placed on ethics in the program that you are affiliated with," 43%responded yes, 50% responded no, and 7% did not respond. Reasons cited for responding no included, they were satisfiedwih the current level of emphasis, or there is no room in the curriculum.

The survey results, with regard to the level of emphasis that should be placed on teaching ethics in the dental hygienecurriculum, indicated that 72% of respondents felt a very high level should be placed on teaching ethics, 25% a high level,3% an intermediate level, and no respondents indicated a low or very low level.

When respondents were asked the most appropriate strategy for incorporating ethics into the dental hygiene curriculum,multiple responses were reported. Eighty percent of respondents indicated that ethics should be incorporated throughoutthe dental hygiene curriculum, fifty percent responded that a separate course on ethics should be offered, and ten percentrecommended ethics be incorporated into a dental hygiene course. With regard to the level of emphasis placed on ethicalconcepts in the didactic and clinical component, results showed the majority of respondents place very high emphasis onall areas of ethical reasoning and professional responsibility, except scientific investigation/research and autonomy. (TableI) (Table II).



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Inferential Findings

One hypothesis possibly explaining the varying emphasis placed on teaching ethics is the differences between the differenttypes of institutions and the degrees they offer. For this study, the researchers classified the types of institutions as technicalcollege, community or junior college, four-year university with a dental school, or four-year university without a dentalschool. Each respondent was asked to name the highest degree offered at his or her institution, from among a choice of acertificate, associate degree, baccalaureate degree, or master's degree. It may be that the varying levels of degrees and/orthe type of institution may play a role in determining the level of emphasis placed on teaching ethics in didactic or clinicalareas.

In this sample, the majority of degrees offered as the institution's highest degree in dental hygiene is the associate degreewith 103. Most of those degrees were offered by community or junior colleges (84). This contingency analysis also revealeda chi-square value of 122.055, significant at the .001 level, which indicates a significant association between the type ofinstitution and the degree offered. The strength of this relationship is moderate with a lambda of .427, a Cramer's V of.530, and a contingency coefficient of .676.

Differences in the Type of Institution

The researchers first looked at the ethics-related questions of the survey and the variances of those responses dependingon the type of institution. For this part of the analysis, the researchers created two, scaled variables that aggregated andaveraged the questions regarding ethics and professional responsibility in the didactic component of a program. In orderto maximize the knowledge gleaned from the data, the authors created two, new scaled variables in the same way for thequestions regarding ethics and professional responsibility in the clinical areas of the programs. The authors created thesevariables by scaling together the 14 questions of the instrument in each substantive area: didactic ethics, didactic professionalresponsibility, clinical ethics, and clinical professional responsibility. In each case, the responses to the 14 questions wereaveraged together to give a single score. These scores appear in Table III. These four, scaled variables provide insight intothe overall emphasis of each respondent in the areas mentioned above. The levels of the scale are 1. very low; 2. low; 3.middle; 4. high; and 5. very high, corresponding to the original questions from which the scaled questions derive. Themeasures in the table below are the means from the scaled variables, which reflect the nuances created by the scales andgive greater understanding to the subtle differences between the institutional types.

Clearly there is less emphasis on professional responsibility than ethics in all institutions. However, the emphasis in allfour areas is very similar with only very slight differences.

Next, the researchers looked for differences in the continuous measures of the study such as the clock hours devoted todidactic and clinical teaching of ethics and the percent of grades derived from demonstrated knowledge of ethical concepts.Table IV shows the findings of that analysis.



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In this analysis, technical colleges seem to devote a noticeably lower number of hours to teaching ethics in both the didacticand clinical areas. All other means seem rather similar, especially considering the sometimes large standard deviations.

The researchers used an analysis of variance (ANOVA) analysis using the type of institution as the factor and all of thevariables in Table V to see if the variance among the types of institutions was greater than the variance among the institutionsof the same type. No significant findings resulted in an ANOVA using the type of institution and the scaled variables onthe teaching of didactic ethics or professional responsibility.

A chi-square analysis was the next step in the analysis of the influence of the type of institution on the emphasis on ethicsin teaching. The only statistically significant variable associated with the type of institution was the variable asking whetherthey used written assignments. That association resulted in a chi-square number of 9.097, significant at the .029 level.Further analysis showed that the association was rather weak, with a non-significant lambda, a contingency coefficient of.241, and a Cramer's V of .249.

Overall, the type of institution seems to have little influence on the level of emphasis in teaching ethics in dental hygienecurricula. Therefore, little may be empirically attributed to the type of institution insofar as instruction in ethics is concerned.

Differences in the Highest Degrees Offered

Dental Hygiene programs offer one of four degrees as their highest, academic degree. Beginning with a certificate, mostprograms also offer either an associate degree, baccalaureate degree, or a master's degree in dental hygiene. The researchersconsidered the influence such differences in degree offerings might have on the level of emphasis in teaching ethics ineach program. Consequently, they performed the following statistical tests to look for that influence. Because of a threatto validity created by disparity in the numbers of respondents in each degree category, the authors combined the certificateand associate programs into a single group entitled "pre-baccalaureate." Because of the low number of respondents whooffered master level programs (6), the authors dropped them from further analysis. For the following analysis, the researchersused the scaled, aggregated variables and looked at the means of each of those variables, and divided them into groupsbased on the highest degree offered by a program. The results follow in Table V.



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Interestingly, this analysis shows the inverse emphases between pre-baccalaureate and baccalaureate programs. On average,pre-baccalaureate programs place a higher emphasis on didactic ethics and clinical ethics. In contrast, baccalaureateprograms generally place a higher emphasis on professional responsibility and clinical professional responsibility.

In the next phase of analysis, the researchers looked for effects of various levels of degrees regarding the continuousvariables available from the survey. The results of that analysis are in Table VI.

Overall, baccalaureate degree programs devote fewer clock hours to both didactic and clinical ethics emphases. In addition,a lower percentage of students' grades in baccalaureate degree programs derive from ethical concepts.

To test this finding further, the researchers performed a t test analysis comparing baccalaureate and pre-baccalaureateprograms in terms of differences in clock hours dedicated to teaching ethics in the didactic area, clock hours dedicated toteaching ethics in the clinical component, and percent of grade derived from ethical concepts. The t test analysis did notshow significant relationships. Likewise, when the researchers analyzed the scaled variables for ethics and professionalresponsibility using a t test analysis, there were no significant relationships.

In a further effort to understand the influence of the highest degree offered (pre-baccalaureate or baccalaureate) on thecurriculum aspects regarding ethics, the researchers used chi-square analysis to examine the effects on some of the discretevariables of the study. From this analysis, four significant associations emerged.

Whether or not the respondents used required chapters from texts for other classes showed a statistically significantrelationship with a chi-square of 6.937, significant at the .008 level. The phi for this two-by-two table was .223, showinga weak relationship.

Use of "other" evaluation mechanisms to evaluate students' ethics understanding also showed a significant associationwith a chi-square of 4.45, significant at the .035 level. The phi of this two-by-two table was .179, again showing a weakrelationship

The type of institution showed a significant association with the pre-baccalaureate or baccalaureate programs with achi-square of 82.098, significant at the .0000 level. The Cramer's V for this four-by-two table was .769, showing, as wouldbe expected, a strong association,

The final association that proved significant was the number of students per graduating class. Grouped into 11-15, 16-20,21-30, 21-30, 31-40, or 41+, analysis revealed a chi-square of 20.755, significant at the .0000 level. The gamma for thisassociation was .643, showing a strong relationship.

Chi-square analysis of all other discrete variables with the pre-baccalaureate and baccalaureate distinction discovered noother statistically significant associations.

Taken as a whole, it seems that the differences between pre-baccalaureate and baccalaureate programs are not very notable.Further research into differences in all the different degree levels, including graduate, might provide more insight into thedifferences in teaching ethics that may exist.



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Discussion

Although the research indicates that the mean hours of ethics instruction has increased, 43% of respondents indicated theywould like more emphasis placed on ethics within their institution. A previous study regarding ethics instruction conducted

in 1982 indicated that 72% of instructors felt that there was enough emphasis placed on ethics in the curriculum.2 Furtherresearch is needed to determine why a greater percentage of respondents would like to see more emphasis placed on ethicsinstruction in this study versus the previous study in spite of the increase in mean hours of instruction that has occurredover the 20+ year period. Perhaps the continued desire for greater emphasis on ethics instruction is relative to the intricacyof dental health and overall health, societal changes, and generational differences.

In a study by Gaston et al,7 the researchers found that dental hygienists reported that they were not prepared to handle

ethical problems that they encountered in the private sector.7 The researchers found that 63% of respondents devoted 10or less hours of instruction in the clinical component of the curriculum, with the majority of evaluation being writtenassessments. The mean percentage of students' clinic grades deriving from ethics was approximately 2%. These findingssupport previous research in which students did not feel prepared to handle ethical dilemmas after graduating, and theneed to increase authentic instruction and evaluation such as engaged real-life learning, role-playing, workshops, and casestudies. Educators must consider not only the quantity of instruction, but also the quality. Shifting to authentic methodsof instruction and evaluation may better prepare students for situations they encounter, and ensure student competence in

handling these dilemmas. In an article by Metcalf et al,12 gaming is being used to assist nursing students with ethics, ethical

dilemmas, and decision making. Metcalf et al12 concluded that the utilization of games when teaching ethics made for anonthreatening environment that allowed students to understand the value of ethics in their chosen profession and to "learn

to live their ethics."12 However, making this shift may present some challenges. A study by Christie et al8 indicated that

faculty found objectively evaluating student competency, with regard to ethics in the clinical setting, a difficult task.8

The research indicates that the majority of individuals teaching ethics in the dental hygiene curriculum are dental hygienefaculty. As the literature review indicates, team-teaching ethics may allow colleagues to incorporate their areas of expertiseinto the ethics curriculum. One method of achieving this would be to collaborate with faculty from other disciplines suchas philosophy or psychology. When reviewing how ethics instruction is incorporated within different degree and certificateprograms, the analysis of the data showed that there was no significant difference. However, the number of programsoffering a separate course in ethics has more than doubled from 31.3%2 to 64% since 1982, which may account for theincrease in mean hours of instruction.

An area of interest with regard to the level of emphasis placed on teaching core values and professional responsibility wasthat the majority of respondents placed a very high level of emphasis in all areas except scientific investigation/researchand autonomy. Clearly, scientific investigation/research is a valuable aspect in the advancement of the dental hygieneprofession and for the dental hygienist to critically evaluate research to determine the efficacy of new theories, interventions,

and technology in order to provide care that is based on scientifc evidence.11 Autonomy is important in dental hygienetreatment to ensure patients' rights with regard to treatment and treatment options. In addition, it assures the hygienist's

right to refuse to provide care that does not meet recognized standards.13

The researchers note the following limitations with the study. The survey instrument was self designed and had noestablished validity or reliability. Respondents indicated it was difficult to compute the number of clock hours devoted toethics instruction in the clinical component of the curriculum. Respondents did not respond to all items in the survey.Respondents selected more than one response for questions that were intended for a single response. Additionally, althoughthe researchers included questions on who is responsible for teaching ethics, they did not ask respondents to indicate theiropinion as to who should teach ethics within the dental hygiene curriculum.



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Conclusion

Ethics is an integral component of dental hygiene education as well as the profession; however, this study revealed that alow proportion of students' clinic grade derives from ethical concepts. Findings also showed that although there is variancefrom program to program, there is no consistent explanation for such variance based on the type of institution offering theprogram or the highest degree offered by the program.

It is clear that dental hygiene programs have taken steps to employ a variety of teaching strategies to assist students indeveloping the skills needed to apply ethical concepts in the provision of oral health care. However, the effectiveness ofinstruction should be assessed. This is evident by the number of respondents who indicated a desire to see a greater emphaison ethics instruction despite the increase in mean hours. Future studies should investigate the effectiveness of ethicsinstruction within the dental hygiene curriculum and how ethics instruction in other allied health disciplines could beapplied to dental hygiene. Such efforts can only enhance the quality of education students receive and in turn the qualityof care provided to patients.

Acknowledgements

Notes

Correspondence to: Mark Kacerik at [email protected]

References1. American Dental Association. Accreditation Standards for Dental Hygiene Education Programs. Chicago (IL): American Dental

Association; 1998. [cited 2003 Sep 20]. Available from: http://www.ada.org/prof/ed/accred/standards/dh.pdf.2. Jong A, Heine CS. The teaching of ethics in the dental hygiene curriculum. J Dent Educ. 1982;46(12): 699-702.3. Competencies for entry into the profession of dental hygiene. J Dent Educ. 2002;66(7): 852-856.4. Odom JG, Beemsterboer PL, Pate T, Haden NK. Revisiting the status of dental ethics instruction. J Dent Educ. 2000;64(11):

772-83.5. Bertolami CN. Why our ethics curricula don't work. J Dent Educ. 2004;64(4): 414-425.6. Odom J. Formal ethics instruction in dental education. J Dent Educ. 1982;46(9): 553-557.7. Gaston MA, Brown DM, Waring M. Survey of ethical issues in dental hygiene. J Dent Hyg. 1990;64(3): 217-224.8. Christie CR, Coun M, Bowen D, Paarmann CS. Curriculum evaluation of ethical reasoning and professional responsibility. J Dent

Educ. 2003;67(1): 55-62.9. Behar-horenstein LS, Dolan TA, Courts FJ, Mitchell GS. Cultivating critical thinking in the clinical learning environment. J Dent

Educ. 2000;64(8): 610-615.10. McCann AL, Campbell P, Schneiderman ED. A performance examination for assessing dental hygiene competencies. J Dent

Hyg. 2001;75(4): 291-304.11. American Dental Hygienists' Association. Code of ethics for dental hygienists. Chicago (IL): ADHA; [cited 2003 Sep 20]. Available

from: http://www.adha.org/aboutadha/codeofethics.htm.12. Metcalf B, Yankou D. Using gaming to help nursing students understand ethics. J Nursing Educ. 2003;42(V): 212.13. Beemsterboer PL. Ethics and Law in Dental Hygiene. St. Louis (MO): W.B. Saunders Co; 2001. 33.



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Differences Between Herbal and Nonherbal Users in DentalPractice

Karen K Tam, Cynthia C Gadbury-Amyot, Charles M Cobb and Karen B Williams

Karen K. Tam, RDH, MS, is a full-time dental hygiene faculty member at Pima Community College; Cynthia C. Gadbury-Amyot, BSDH,EdD, is professor and director, division of dental hygiene, University of Missouri-Kansas City; Charles M. Cobb, DDS, PhD, is professoremeritus, department of periodontics, University of Missouri-Kansas City; Karen B. Williams, RDH, MS, PhD, is professor and director,clinical research, school of dentistry, University of Missouri-Kansas City.

Purpose. The purposes of this study were to describe basic demographics and health belief differences between herbusers and nonherb users, any potential herb-drug interactions, and examine the association between dental chart notedand questionnaire self-reported use of herbal remedies.

Methods. A 3-part survey instrument was administered to a convenience sample of 149 individuals at a dental clinicand two dental practices. The first part ascertained demographic information and prescription drug use using open-endedand closed-ended questions. The second part listed 51 individual/combination herbs and the third part assessed healthcarebehavior using a 5-point Likert scale. A chart audit compared written responses between a patient's medical/dentalhistory chart and his/her survey on herbal use. Descriptive analyses and MANOVA were used to examine the relationshipbetween herbal users and nonusers.

Results. Eighty participants (54%) reported using some form of herbs. They were characterized as mostly female (71%),who were less likely to disclose herbal usage to practitioners (p< .05), believed in herbal effectiveness (p< .05), andreported a more positive perceived level of health status compared to nonusers (p= .02). Although herb users reporteda willingness to disclose use of herbs to health practitioners, only three patients had any written documentation of theirherb use in their medical/dental health chart (p= .0001). Fifty-five herb users were also taking prescription drugs (69%)that could potentially lead to herb-drug interactions.

Conclusion. The findings provide supportive evidence that dental hygiene practitioners need to be aware of their patients'use of herbs. Knowing potential risks, side effects, and possible drug interactions is necessary for patient managementand each patient's oral health.

Keywords: Herbal remedies, herb-drug interactions, alternative medicine, public health

Introduction

Alternative medicine has become a significant public health concern among health care professionals.1-13 More than one-halfof the US adult population uses some form of alternative therapy to treat actual or perceived ailments and/or to prevent

perceived threats to their general health.5 Alternative therapy encompasses a wide variety of methods including reflexology,acupuncture, megavitamin therapy, folk remedies, and herbal remedies. Herbal remedies or herbal medicines are defined

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as the use of preparations and medications derived from botanical components such as roots, leaves, and flowers to promote

healing.9 These components can be used in raw, pill, or capsule form. The current study focused on the use of herbalremedies.

In the first US national survey on the number of people using herbal therapies, Eisenberg documented an almost 10%

increase from 2.5% in 1990 to 12.1% in 1997 among those who used herbal therapies.5 Since the time of Eisenberg's study,

other analyses have found similar results in the increase of herbal use among people in the United States.14-16

Issues related to quality control, safety, and effectiveness are major concerns with herbal medicine. Today, there is anaggressive push to collect data on popular herbal remedies, their efficacy, and their potential adverse affects when usedeither alone or with other medications, or medical treatments. Several long-term studies to answer these questions havebeen undertaken in the United States with the support of the National Center for Complementary and Alternative Medicine

(NCCAM), a component of the National Institute of Health, in collaboration with various universities around the country.13,17

With herbal sales now estimated to be a $4 billion a year industry, health professionals increasingly turn to researchers to

provide scientific information on herbal efficacy and safety.18

Although there are numerous studies regarding medical patients using herbal remedies, there is an absence of studiesexamining the impact of herbal remedies on dental patients. In dentistry, medications are prescribed for many reasons,including treating oral disease and preventing infections after surgical procedures such as tooth extractions. Therefore,maintaining a current medical history of each patient is vitally important. It has been stated that the most common cause

of prescription drug related interactions is the dental practitioner's lack of information about the patient's medical history;14,21

including whether or not the patient is using dietary supplements and herbal remedies. Some herbs have the potential tointeract with other medications, which can affect dental management and treatment.

People choose to use herbal remedies for a number of reasons. According to a Harvard University informal survey, one

in three dental patients acknowledged using one, or a combination of, herbal medication(s).3 Therefore, the purposes ofthis study were: to describe the basic demographics and health belief differences between herb users and nonherb users;to address any potential drug-herb interactions; and to examine the association between dental chart noted and questionnaireself-reported use of herbal remedies.


The use of herbal plants extends back to the Neanderthal period.8 For thousands of years, people have used herbs to cure

and prevent disease, especially in Europe and Asia where, to date, physicians still prescribe natural remedies.19-22 By the

1900s, with advanced conventional medicine, the use of herbs began to diminish in the United States.23 With a risinginterest in holistic health, herbal remedies have steadily regained public acceptance and popularity from the 1960s to

present.1,8,18

The requirements for monitoring the safety and efficacy of herbal medicines is not the same as for prescription drugs.Unlike prescription drugs, herbal medicines are not required to undergo extensive research to demonstrate safety, efficacy,and quality control. In 1994, under tremendous pressure from consumers and health food stores, Congress passed the

Dietary Supplement Health and Education Act (DSHEA), which defined herbal remedies as dietary supplements.4,8,22 Still,there is no FDA review or approval of these supplement products and their ingredients. Food additives are submitted to a

more rigorous approval process than herbal products.10,24 Under the DSHEA, the responsibility falls on the consumer toalert the FDA with questions about a product's safety. Once alerted, the FDA must prove the product unsafe before any

restrictions can be placed on the product.8,22,24 By 1998, the FDA required that labels on herbal products must inform

consumers that the herbal manufacturer's product "is not intended to diagnose, treat, cure, or prevent any disease."22,24

Statements that once said, "decreases blood pressure" were changed to "promotes vascular health."



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The newest proposed ruling regarding herbal products (2003) by the FDA states that dietary supplement manufacturersare now required to follow good manufacturing practices in the way they manufacture, pack, and store their products. Thiswill ensure accurate labeling and unadulterated products as well as enforce better quality control and testing of manufactured

dietary supplements and their ingredients.25 This is a big step since quality control on herbs has been difficult in the past.Herbs can vary from batch to batch as a result of herb plant variation. Batches of herbal plants may become tainted duringthe processing stages of cultivation, harvesting, and storing. In some herbal plants, different parts of the plant (stem, leaves,

or roots) contain varying degrees of potency or toxicity when processed.2,6,7 If the poisonous part of a plant is processed,the results could be toxic.

Although most herbs are relatively safe, the concern here is that most reported reactions caused by herbs are usually mildand may be overlooked by the people who took them as well as healthcare practitioners.2, 26, 27 Common reactionsinclude: headaches, diarrhea, nausea, dermatitis, allergic reactions, dizziness, palpitations, photosensitivity, insomnia,

tiredness, agitation, and sedation. 2,4,7,8,26-30 In higher doses, herbal remedies may cause severe symptoms, and may include

hematomas, hepatotoxicity, abdominal distention, and liver disease.2,4,7,8,26-29

Another important concern is patient disclosure of herbal use. Research on patient disclosure of herbal use in the UnitedStates has been contradictory. Several empirical survey research studies on herbal use disclosure reveal that approximately

50 to 70% of patients do not consult their general practitioners about their herbal use.3,5,11 Identified reasons for lack ofdisclosure of herbal use relates to the patient's perception of a poor or negative attitude of healthcare practitioners regarding

herbal use and a general lack of communication between healthcare practitioners and their patients.2,5,7,9,23,31 Most patients

do not disclose herbal use to their healthcare providers believing herbals, as dietary supplements, are naturally safe.2,26,27

In contrast, a recent survey conducted by Klepser et al14 found that herb users were actually open to disclosing their herbaluse to their physicians and believed that it was important for their physicians to be aware of their herbal use. However,

the investigators did not report if those patients were currently revealing herbal information to their physicians.14 A national

survey conducted by the Consumers Union in 200015 found that 60% of the respondents who reported using herbalsdisclosed their use to their doctors, and felt comfortable doing so. These respondents further reported that 55% of theirdoctors expressed approval of the use of alternative therapies, while 40% were neutral, and 5% disapproved. The resultsfrom this national survey suggest that physicians in the United States may be changing their attitudes toward herb use

when compared to previous studies on the attitudes of medical physicians on alternative medicine.14,15

Despite practitioners' concerns about herbal safety, efficacy, and disclosure, over-the-counter herbal remedies remain amulti-billion dollar enterprise. In several studies, most Americans reported that they would first try self-medication withover-the-counter medications and herbal remedies before visiting a physician for simple conditions such as nausea,

headaches, and allergies.1,4,5,16,26-30,32,33

In an attempt to more fully understand or describe the characteristics of individuals who are more likely to practice self-care,

researchers have examined health-related belief measures.35-37 One health belief measure is the Health Locus of Control(HLC), which has been used to determine the type of control one exhibits in their behavioral approach and decision-making

on health-related issues.34,35,44 A person's HLC originates from an individual's perception regarding their health conditionand their health behaviors. Individual perceptions include the level of self-esteem and self-awareness, how much importanceis placed on their health, and the benefits of taking certain actions. Other factors such as age, demographics, income, andeducation can also affect how a person behaves and makes decisions concerning health-related issues.

The HLC identifies three main dimensions of perception. Although an individual may appear to exhibit all three perceptionsat different times, one dimension of perception usually dominates the other two in decision making. The first HLC dimensionis internal control. These individuals exhibit a strong sense of empowerment in their own health outcomes. Duffy foundindividuals with a strong dimension of internal control tend to be more proactive in applying what they believe to be a

healthy lifestyle.36,37 The second HLC dimension is external control. These individuals generally rely on "powerful others"to make decisions concerning their health or recovery from illness. Duffy found these individuals to be passive and



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compliant. Thus, they believe management of their health is beyond their personal control, and they rely on the provider

to make decisions for them.36 Last, the chance HLC or fatalistic dimension perceives health as predetermined by bad luck,chance, or fate. Strategies used in this perception are usually prayers or lucky charms with little regard for professional

advice.36,37

Furnham and Smith,35 and Astin43 used a health belief measure to study behaviors among patients visiting a homeopathand patients visiting a general practitioner. These researchers reported that internal control and being proactive over their

health decisions were important to herbal users, particularly to subjects in Furnham and Smith's study.35 Those who usedherbal medicine generally sought methods that were aligned with their health belief and the belief that the body is capableof healing itself. At this time, no studies on herbal use by dental patients and health beliefs have been reported.

With an increasing number of people educating themselves and actively seeking unconventional remedies without involving

their health care providers, the issue and concern of herbal use safety continues to intensify.1,2,4-7,11,38 The issue of qualitycontrol makes drug-herb interactions less predictable and possibly less recognizable for individuals who self-medicate

and for their health care providers.39 Although most drug-herb interactions are not clearly understood, herbal remedies can

increase, decrease, or inactivate the effectiveness of prescription drugs.4,39-42 For example, several studies found that St.John's wort greatly compromises the action of two prescription drugs, indinavir, an HIV protease inhibitor drug, and

cyclosporin, an immunosuppressor drug used to prevent organ transplant rejection.29,40,42 The indinavir drug was quicklyeliminated from the body by St. John's wort, whereas cyclosporin was inactivated.

Methods and Materials

The purposes of this study were: to describe the basic demographics and health belief differences between herb users andnonherb users; to address any potential drug-herb interactions; and to examine the association between dental chart notedand questionnaire self-reported use of herbal remedies in a dental setting.

A survey was developed to collect data regarding respondent demographics, prescription and/or herbal products used, andindividual health belief systems. The clarity of the questionnaire was established using a convenience sample of 10 subjectsat the University of Missouri-Kansas City (UMKC) dental clinic. Some questions were phrased to capture the same issuein both negative and positive statements to ensure reliability in interpretation and to gather information of patient knowledgeof herbs. Results were used to improve item clarity in order to reduce error variance. The UMKC Institutional ReviewBoard approved the survey and administration techniques.

The population studied was a convenience sample drawn from the dental school general clinic patient population and twoprivate general dental practices. These sites were chosen because of their distinct differences in demographics accordingto age, ethnicity, education, and annual income. The sample group included 153 adult dental patients. A sample size of

150 subjects was determined to be sufficient to provide stable estimates for multivariate analyses.45 In the waiting roomof each site, a single investigator approached each patient as they signed in to receive dental treatment and invited themto participate in the study. At each site, over a 2 ½ week data collection period, 51 dental patients completed a writtensurvey questionnaire and seven declined to participate. In all, during a visit at one of the three sites, 153 individuals signeda consent form to participate and completed the written questionnaire, regardless of their herbal use.

After the subjects completed the written questionnaire, the investigator conducted a chart audit. At each site, the primaryinvestigator used a standardized form to record the dental/medical history of each patient. All data was coded to maintainconfidentiality.

Nonusers were defined as subjects who had not used herbal remedies in the past year. Herbal users were defined as subjectsthat were currently using or had used an herbal therapy or a combination of herbal therapies in the past year.

This study was comprised of two components: a 3-part questionnaire and a chart audit. The questionnaire covered twobasic areas: (a) demographic information; (b) herbal and prescription drug use. A chart audit was used to determine if



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updates on prescription, over-the-counter, and herbal medications were recorded in the permanent dental record, whoupdated the subject's medical history, subject's dental treatments, and any known allergies.

The written questionnaire was developed to elicit information on dental patients' herbal use, demographics (socioeconomicstatus, education, geographic region, age, gender, and health care status), and health belief locus of control. The first partof the questionnaire consisted of open-ended and closed-ended questions on demographic information, current prescriptionmedication use, and for what condition the medication was being taken. The second part listed 37 specific herbal remediesin alphabetical order, 14 herbal combinations, and an "Other" column for any herbal remedies and combinations not listed.The third part consisted of 35 items to measure six subscales of health belief and patient attitudes toward herbs using a5-point Likert scale (1=strongly agree, 5=strongly disagree). The six subscales of health belief seen in Table I are asfollows: 1) Internal Locus of Control (LOC)-8 items; 2) External LOC-8 items; 3) Chance LOC-6 items; 4) Health ThreatLOC-4 items; 5) Effectiveness LOC-2 items; and 6) Disclosure LOC-4 items. Three additional items were also includedto measure the perception of health status, herbal safety, and prescription drug safety.



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Survey items in the third part of the questionnaire were adapted from three different sources. Eight items on safety,

effectiveness, and patient disclosure belief were taken from Klepser.14 One item was taken from a study by Astin 43investigating possible predictors of alterative health care use. The item was used in this study to describe patients' perceivedlevel of health status. Twenty-six items were used from Lau and Ware's research on the construct of the health belief

model.34 Results from their analysis ascertained four distinct health-specific loci of control subscales (internal, external,chance, and health threat).



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This study set out to extend previous work by looking at dental patients and herbal use. Hypotheses of this study are asfollows:

There will be a difference between herbal users and nonherbal users with respect to demographics (education, economics,race, gender, and age) and health belief system as measured by health locus of control items (internal, external, and chancecontrol);

There will be potential herb-drug interactions among herb users using prescription drugs; and that

There will be a difference between dental chart noted and questionnaire self-reported use of herbal remedies as measuredby comparing written documentation in the health history form to survey questionnaire.

Data from this study were analyzed in the following manner. Chi-square analysis (i.e., comparing observed frequenciesto expected frequencies) was used to examine the association between self-reported use by the written questionnaire andself-reported use of herbs as determined by the written medical history from the chart audit. Differences between herbalusers and nonusers with respect to demographics: gender, age, ethnicity, education, income, and health belief system werecompared using chi-square analysis.

The MANOVA statistical test was used to compare herbal users and nonusers across subscale scores. The relationshipbetween a patient's self perceived health status and the use or the nonuse of herbs was examined using the Mann-WhitneyU statistical test.

Results

Of the 153 surveys obtained from dental patients at three dental treatment sites, 149 (97%) were used for analysis. Foursubjects were removed due to unavailability of charts for conducting the chart audit and one subject also did not completethe survey because of shortage of time before the appointment.

Fifty-three percent of the sample identified themselves as herbal users (Table II). There was a significant difference ingender (p< .001) among herb users with the use of herbs significantly higher among women (71%) compared to men(29%). Additional analyses detected no differences between herbal users and nonusers with respect to the remainingdemographic data collected: age, ethnicity, education, region, and income.



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One of the primary purposes of this study was to characterize herbal users and nonusers as a function of health beliefsystem. Internal consistency estimates of reliability (Cronbach's a) were calculated for each of the defined subscales.Effectiveness, External Locus of Control and Patient Disclo sure subscales had acceptable reliability coefficients (a = .67;.77; .78, respectively). Therefore, all items in these original subscales were maintained. Analysis of the remaining subscales

showed some items did not contribute to the scales' internal consistency as shown in Table III. Consequently, items weredeleted from subscales Internal Locus of Control (LOC) and Chance LOC to increase the reliability coefficient (Table I).The Health Threat LOC had a reliability coefficient of -0.07 for the original items and did not show consistency amongany items. This subscale was omitted from subsequent analyses.

MANOVA was conducted to examine differences across health belief subscales as a function of herbal use. There was astatistically significant difference across health belief subscales (Hotellings T = .347, p= .0001) as seen in Table IV. The



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overall η2 of .26 suggests that there was a large meaningful difference across subscales means of herbal users and nonusersin overall beliefs. To determine the mean for each subscale, the negative items from the Likert scale were inverted to bepositive items. Then each reported score in the subscale was added and divided by the total number of items. Univariatefollow-up analyses were used to examine health beliefs by subscales between herbal users and nonusers. These analysesshowed that the subscale Herb Effectiveness largely influenced the overall differences between groups. The herb usergroup had a lower mean on the effectiveness subscale (4.7; sd 1.5) than the nonuser group (6.0; sd 1.2), illustrating a

stronger belief in the effectiveness of herbs in improving their health (p< .0001, η2 =. 20). No differences were foundbetween users and nonusers with respect to Internal LOC, External LOC, Chance LOC, and Patient Disclosure subscales.

A logistic model was subsequently fitted with herbal use modeled as a function of seven selected predictor variables toproduce odds ratios. Table V presents the b weights, standard error, significance, and odds ratio with 95% CI for the final

logistic model. The results supported gender (p≤ .001), herb effectiveness (p≤ .001), and patient disclosure (p≤ .005) assignificant predictors of herbal use.



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The odds of females using herbal remedies were 4.67 times greater than for males (95% CI = 1.80, 12.40). In this study,71% of herbal users were females compared with 29% males. The odds of herbal use were 2.56 times greater for eachincrease in score level unit for those who believed in herbal effectiveness (95% CI =1.60, 4.40). Sixty percent of herbalusers believed that herbs do improve overall health compared to only 12% of nonusers. In addition, 59% of herbal userrespondents believe family members agree that herbs improve health compared to 20% of nonusers. Finally, the odds ofpatients' willingness to disclose herbal use to health practitioners were significantly less for users than nonusers (OR .73;CI= 0.59, 0.91). The findings revealed only 3 of the 80 herb users (3.8%) reporting use of herbals actually had documentation

of their herbal use in their dental record (Table VI). This difference was statistically significant (X2 = 68.45, p ≤ .001).

This study identified five herbs most frequently used: echinacea, ginseng, garlic, gingko biloba, and St. John's wort,respectively. Table VII documents the number of potential herb-drug interactions of the herbal users. Of the 88 herbalusers, 55 were also taking prescription drugs. A total of 24 various potential herb-drug interactions were recorded. Subjectstaking echinacea were also taking prescription medications that were not contraindicated with the herbs. Likewise, subjectstaking synthroid and gastrointestinal drug therapies were taking herb remedies that were not contraindicated.



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Discussion

The focus of this study was to describe basic demographics and health belief differences between herb users and nonherbusers, to address any potential herb-drug interactions, and to examine the association between dental chart noted andquestionnaire self-reported use of herbal remedies. One of the most significant findings of this study was the lack ofdocumentation in the dental record compared to self-reported herbal use as reported by study participants in the writtensurvey. Chart audits revealed that more than 96% of herbal users did not have any written documentation of herbal use in

their dental chart. These findings are similar to the findings reported from several other studies.3,5,11,14 When study participantswere asked whether physicians and dental practitioners should be made aware of the use of herbal therapies, a majorityresponded positively. However, less than 4% had documentation of their herbal use in their dental chart. The discrepancybetween the lack of documentation and the willingness to disclose the use of herbs may be due to several reasons identifiedby this study and previous studies.

First may be the perception of patients that herbal remedies may not be considered medications.4-10,21,28 It is possible thatherbal users view herbal remedies like over-the-counter dietary supplements and vitamins. Most medical histories do notseparate traditional prescription medicine from alternative medicine. If this is the case, voluntarily disclosing herb use tohealthcare practitioners may not seem relevant to herb users. Also, researchers have hypothesized that a lack of trust

between the patient and their provider could cause the patient to feel uncomfortable in disclosing their use of herbals.3,7,9,11,23,31

If the patient perceives disapproval from healthcare providers about their use of herbs, the patient becomes less likely todisclose using them. In this study, the written questionnaire specifically asked the patient to disclose any herbs beingpresently taken, and that may be one reason for the large number of herbal use disclosures in the surveys compared to theirmedical charts. Patients may be more willing to disclose the use of herbs if asked directly by their healthcare practitioner.However, this study did not ask the provider if they asked patients about herbal use during the medical history review orupdates.



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Regarding differences between groups with respect to demographics and health belief system, the only demographicvariable that was significant was gender, with women reporting higher use of herbals than men. This finding supports

several studies that reported women as more likely than men to use herbal remedies.5,33,43 Traditionally, women tend to be

greater health seekers than men, so it is not surprising to find women more willing to try herbal remedies.5 Interestingly,in this study two male subjects commented that they were not sure why they were taking herbal remedies, but that theirwives included them into their daily regiment along with their prescription or vitamin therapy. These results seem tosupport the theory that women are more likely to be herbal users and look for preventive therapies.

The seven predictors: Internal LOC, External LOC, Chance LOC, health status, herb effectiveness, herb disclosure, andsafety of herbs and prescriptions used in this study had been previously identified as predictors of herbal use by otherinvestigators, however study results were mixed. Results from this study, along with Vincent and Furnham (1996), Eisenberget al (1998), Klepser et al (2000), and Palinkas and Kabongo (2000), found gender, herbal effectiveness, and herbaldisclosure to be good predictors of herbal use. However, Furnham and Forey (1994), Eisenberg et al (1993), and Astin(1998) did not. With the remaining predictors, evidence for whether or not health belief loci of controls and health status

perception predict herb users was also found to be equivocal.5,35,43,44

Reasons for no differences between the herb users and nonherb users health belief loci of controls are difficult to ascertainin the current study. Future studies might include a personal interview that could help the researcher extrapolate greaterinformation about health belief loci of control in both groups.

Perhaps health behavior is more complex and in-depth and intertwines with certain cultural beliefs that these questionson health behaviors are not capable of fully explaining. It would seem that predicting use of herbals is multifaceted, whichis why the results are mixed among studies. Further studies are needed to identify additional predictors of herbal use.

Another finding of particular interest in this study was the potential for adverse associations between herbals and/or drugsand certain dental procedures. Results from this study showed that 54 herbal users (68%) were scheduled to receive somesort of invasive dental treatment (restorations, periodontal surgery and maintenance, root canals, and tooth extractions)with many of these treatments requiring the use of local anesthetic. Because many of these dental treatments involvebleeding, herbal use such as gingko biloba, garlic, and ginseng should be of concern to the practitioner due to their potentialfor causing excessive bleeding. Although, no research has actually examined the interaction of local anesthetic and herbalremedies, warnings related to potential interactions between general anesthetic agents and herbal remedies have beenexplicit. The American Society of Anesthesiologists (2000) issued a warning in 1999 on the risk for herb-anesthesiainteractions for surgery patients and the importance of including herbal remedies as part of the medical history. Herbalremedies such as valerian, ginseng, gingko biloba, and several others have been known to interfere or increase effects of

anesthesia as well as complicate preoperative preparations to surgery.11,46,47

Potential herb-drug interactions for study participants are shown in Figure 1. Results from this study revealed that 55 studyparticipants, more than half of those using herbal remedies, were also using prescription drugs (69%). Because this studyonly examined the five most commonly used herbals and five most commonly used prescription groups, the potential forinteractions was limited to these herbals and prescription drug groups. With the exception of the herb echinacea, therewere potential herb-drug interactions with the following herbs: ginseng, garlic, gingko biloba, and St. John's wort. Theseherbs have potential interactions mostly with cardiovascular and analgesic therapies. Participants in this study takingantiarrhymia, antihypertension, diurectics, beta-blockers, anticoagulant, and calcium channel blockers medications werecategorized as using Cardiovascular therapy. Cardiovascular drugs, when used with ginseng, gingko biloba, and St. John'swort, have been reported to increase antiplatelet effects, exacerbate effects, or augment and decrease effects of certain

medications.6,28,39 Participants taking non-steroidal anti-inflammatory drugs (NSAIDS) and aspirin were categorized asusing analgesic therapy. Concomitant use of analgesic therapies with herbs such as ginseng, garlic, or gingko biloba have

been shown to increase antiplatelet effects and cause further damage to the gastrointestinal area.6,8,11,39,46 Other potentialdrug interactions of concern in this study were concomitant use of antidepressants with St. John's wort or gingko biloba.Interactions include increased sedation effects and possible decrease of threshold with certain antidepressants used in

treating patients for seizures.6,8,48



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Certain limitations of this study must be acknowledged when the implications of study results are considered. Thegeneralizability of the results in this study is limited by the small sample size and the fact that participants were from asingle metropolitan area. In addition, the potential for bias, as a result of the self-report survey design, also must beconsidered in interpreting the results.

Further studies are needed to examine other potential predictors of herbal use such as religion and spiritual beliefs. Personalinterviews may be a way to extrapolate additional information as well as clarify ambiguity with health-specific loci ofcontrols. Soliciting information from herbal users on actual reactions and side affects would help practitioners and patientsgain a better understanding of how herbal usage impacts the body. Changes in the work environment such as asking clientsof any herbal use and documenting its use may contribute to greater information on behaviors of herbal users as well asassessing the information for potential adverse affects and reactions.

Conclusion

The survey findings do provide and contribute a better understanding of those who use herbs, specifically within a dentalpractice setting. Understanding behaviors and characteristics of those who are likely to use herbs is essential for recordingand maintaining comprehensive health histories. In an era when so many people are self-diagnosing and self-medicating,it is the healthcare practitioner's responsibility to help patients become better informed to make safe and appropriate healthrelated choices. Finding out the kind and reasons for herbal use will help dental hygiene practitioners inform patients ofany possible harmful interactions that they may not be aware of while supporting individuals in their beliefs and attitudesabout herbs. Dental hygienists should provide dental patients with information of potential drug-herb interaction, adversereactions, and side effects especially with those requiring tooth extraction, periodontal surgery, and other complex dentaltreatments where bleeding and anesthetics are a concern.



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To treat the new population of self-medicating patients, healthcare professionals need to be open and receptive to patients'health-related beliefs. By communicating and asking patients whether they use herbal remedies, practitioners can thenresponsibly advise or inform patients of potential interactions involving their dental treatment or drug-herb interactions.

Acknowledgements

Supported in part from funding from the University of Missouri-Kansas School of Dentistry Rinehart Foundation

Notes

Correspondence to: Karen K. Tam [email protected]

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Oct;14(5): 339-50.2. D'Arcy PF. Adverse reactions and interactions with herbal medicines: Part 1-Adverse reactions. Adverse Drug React Toxicol

Rev. 1991;10(4): 189-208.3. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States.

Prevalence, costs, and patterns of use.. N Engl J Med. 1993. Jan28;328(4): 246-52.4. Crone CC, Wise TN. Use of herbal medicines among consultation-liaison populations. Psychosomatics . 1998. Jan-Feb;39(1):

3-13.5. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Rompay M, Kessler RC. Trends in alternative medicine use in the United

States: results of a follow-up national survey 1990-1997 . JAMA. 1998. Nov11;280(18): 1569-75.6. Miller LG. Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern

Med. 1998. Nov9;158(20): 2200-11.7. Vann A. The herbal medicine boom: understanding what patients are taking. Cleve Clin J Med. 1998. March;65(3): 129-34.8. Winslow LC, Kroll DJ. Herbs as medicines. Arch Intern Med. 1998. Nov9;158(20): 2192-9.9. Karimi K. The impact of current alternative herbal remedies on dental patient management . Gen Dent. 1999. May-June;47(3):

264-6.10. Sabar R, Kaye AD, Frost EA. Perioperative considerations for the patient taking herbal medicines. Heart. 2001. Mar-Apr;3(2):

87-96.11. Cheng B, Hung CT, Chiu W. Herbal medicine and anaesthesia. Hong Kong Med J. 2002. Apr;8(2): 123-30.12. Lyons TR. Herbal medicines and possible anesthesia interactions. AANA J. 2002 . Feb;70(1): 47-51.13. Marcus DM, Grollman AP. Botanical medicines-the need for new regulations. N Engl J Med. 2002;347: 2073-6.14. Klepser TB, Doucette WR, Horton MR, Buys LM, Ernst ME, Ford JK, Hoehns JD, Kautzman HA, Logemann CD, Swegle JM,

Ritho Klepser, ME secondauthorgivenname. Assessment of patients' perceptions and beliefs regarding herbal therapies.Pharmacotherapy. 2000 . Jan;20(1): 83-7.

15. Mainstreaming of alternative medicine. Consumer Reports. 2000. May;65(5): 17-25.16. Conover EA. Over the counter products: nonprescription medications, nutraceuticals, and herbal agents. Clin Obstet Gynecol.

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Health. Bethesda (MD): NIH. [cited 2001 Sep 3]. Available from: http://nccam.nih.gov/ne/press-releases/092000.html.18. John Carey. Herbal remedies: a $4 billion enigma. Business Week. 2003. Apr28;(3830): 104.19. Goldbeck-Wood S, Dorozynski A, Lie L, Yamauchi M, Zinn C, Josefson D, Ingram M. Complementary medicine is booming

worldwide. Br Med J. 1996. Jul20;(7050): 313-3.20. Harrison P. Herbal medicine takes root in Germany. CMAJ . 1998. Mar10;158(5): 637-9.21. Biron CR. Some precautions about herbs. RDH. 1999 . Oct;19(10): 90-91.22. Rheingold Paul. FDA needs herbal remedy. National Law Journal. 2003. Apr21;78(issue): firstpage-lastpage.23. Goodwin JS, Tangum MR. Battling quackery: attitudes about micronutrient supplements in American academic medicine. Arch

Intern Med. 1998 . Nov9;158(20): 2187-91.24. Kurtzweil P. An FDA guide to dietary supplements. FDA Consum. 1998. Sept.-Oct;32(5): 28-35.



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25. US Department of Health and Human Services. FDA proposes labeling and manufacturing standards for all dietary supplements.Bew PO3-14. Washington (DC): FDA; 2003. Mar7.

26. De Smet Pa. Health risks of herbal remedies. Drug Saf. 1995. Aug;13(2): 81-93.27. Klepser TB, Klepser MA. Unsafe and potentially safe herbal therapies. Am J Health Syst Pharm. 1999. Jan15;56(2): 125-38.28. Vickers A, Zollman C. ABC of complementary medicine: herbal medicine. Br Med J. 1999. Oct;319(7216): 1050-3.29. Turton-Weeks firstauthorgivenname, Barone GW, Gurley BJ, Ketel BL, Lightfoot ML, Abul-Ezz SR. St. John's wort: a hidden

risk for transplant patients. Prog Transplant. 2001. Jun11;(2): 116-20.30. Bent S, Tiedt TN, Odden MC, Shlipak MG. The relative safety of ephedra compared with other herbal products. Annals of Int

Med. 2003. Mar15138(6): 468-472.31. Dalen JE. "Conventional" and "unconventional" medicine. Can they be integrated?. Arch Intern Med. 1998. Nov9;158(20):

2179-81.32. Americans at risk from self-medication, survey reveals. Am J Health Syst Pharm. 1997. Dec1;54(23): 2664-2666.33. Palinkas LA, Kabongo ML. The use of complementary and alternative medicine by primary care patients. A Surf *Net study. J

Fam Pract. 2000. Dec;49(12): 1121-30.34. Lau RR, Ware JF. Refinements in the measurement of health-specific locus-of-control beliefs. Med Care. 1981. Nov;19(11):

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homeopath. Soc Sci Med. 1988;26(7): 685-9.36. Duffy ME. Determinants of health promotion in midlife women. Nurs Res. 1988. Nov-Dec;37(6): 358-62.37. Duffy ME. Determinants of health-promoting lifestyles in older persons. Image J Nurs Sch. 1993 . Spring;25(1): 23-8.38. Leak J. Herbal medicine: Is it an alternative or an unknown? A brief review of popular herbals used by patients in a pain and

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Feb12;355(9203): 547-8.41. Chen JK. Nephropathy associated with the use of aristolochia. Herbalgram. 2000. Spring;48: 44-5.42. Ruschitzka F, Meier PJ, Turina M, Lüscher TF, Noll G. Acute heart transplant rejection due to Saint John's wort. Lancet. 2000.

Feb12;355(9203): 548-9.43. Astin J. Why patients use alternative medicine: results of a national study. JAMA. 1998. May20;279(19): 1548-53.44. Furnham A, Forey J. The attitudes, behaviors and beliefs of patients of conventional vs. complementary (alternative) medicine.

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Oct;56(5): 754-61.46. Heyneman CA. Preoperative considerations:which herbal products should be discontinued before surgery? . Critical Care Nurs.

2003. Apr;23(2): 16-24.47. American Society of Anesthesiologists. What you should know about herbal use and anesthesia. Park Ridge (IL): ASA; 2000.

[cited 2003 Aug 9]. Available from: http://www.asahq.org/patient education/insideherb.html.48. Lantz MS, Buchalter E, Giambanco B. St. John's wort and antidepressant drug interactions in the elderly. Geriatr Psychiatry

Neurol. 1999. Spring;12(1): 7-10.



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Sulcular Sulfide Monitoring: An Indicator of Early DentalPlaque-Induced Gingival Disease

Aleksandra Pavolotskaya, Gayle McCombs, Michele Darby, Kenneth Marinak and Naik N Dayanand

Aleksandra Pavolotskaya, RDH, MS, is a clinical lecturer at Indiana University School of Dentistry, Department of Periodontics,Division of Dental Hygiene, Indianapolis, IN. Gayle McCombs, RDH, MS, is an associate professor and director at the Dental HygieneResearch Center, Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University, Norfolk, VA. Michele Darby, BSDH, MS,is a professor and the graduate program director of Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University, Norfolk,VA. Kenneth Marinak, DDS, is a private practitioner/periodontist, Virginia Beach, VA. Dayanand N. Naik, PhD, is a professor in theDepartment of Mathematics and Statistics at Old Dominion University, Norfolk, VA.

Purpose. The purpose of this study was to evaluate the relationship between volatile sulfur compounds (VSC) andgingival health status and to determine if volatile sulfur compounds can detect early dental plaque-induced gingivaldisease.

Methods. A split-mouth design with randomly selected quadrants of the mandibular arch enabled 39 participants toserve as their own controls. At baseline and at three subsequent appointments (days 7, 14, and 21) gingival inflammation(GI), bleeding on probing (BOP), and sulfide levels (SUL) were measured using the Gingival Index and the DiamondProbe/Perio 2000 System. For three weeks, participants refrained from brushing and flossing one randomly selectedquadrant of the mandibular arch. The Pearson correlation test was used to determine the relationship between sulfideconcentrations and gingival health. The Wilcoxon signed rank test was used to compare the differences in mean GI,BOP, and SUL scores between the hygiene side (H) and the non-hygiene side (NH).

Results. Data suggest that SUL correlate positively to GI and BOP on both sides; however, the strength of the correlationwas stronger for the NH side. A comparison of mean GI, BOP, and SUL scores revealed a statistically significantdifference between sides for all three parameters from baseline to day 21, except for SUL on day 14.

Conclusions. Based on study outcomes, the Diamond Probe/Perio 2000 System demonstrated the ability to detect siteswith elevated SUL; therefore, SUL may be a useful adjunctive indicator of early plaque-induced gingivitis. In addition,data revealed a moderate correlation between SUL levels and gingival inflammation on the NH sides. Whether sulfurby-product is a contributor to the disease process, or merely a correlate, is inconclusive.

Keywords: gingivitis, volatile sulfur compounds, Diamond Probe/Perio System

Introduction

Periodontal disease includes a group of inflammatory conditions of the periodontal tissues broadly categorized as gingivitis

and periodontitis. Inflammation of the gingiva induced by plaque biofilm is the most common form of gingivitis.1

Experimental research in humans has long confirmed bacterial plaque as a cause of gingival disease.2 Moreover, the

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American Academy of Periodontology supports the theory that the initiation and progression of most forms of gingivitis

are dependent upon the presence and persistence of specific pathogens in bacterial plaque.3 As gram-negative bacteriacross the epithelial barrier into the underlying connective tissue of the periodontium, an inflammatory reaction in the hostis initiated, leading to connective tissue breakdown. Gram-negative bacteria have the potential to generate volatile sulfurcompounds (VSC), specifically, hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide (CH3SCH3),

as by-products of their metabolism.4 These by-products of bacterial metabolism may be factors in the etiology and

pathogenesis of periodontal disease.5

Numerous studies reveal that sulfur by-products are associated with periodontal disease.6,7,8 Additionally, researcherssuggest that even in low concentrations, VSC are highly toxic to periodontal tissue and may contribute to the etiology of

gingivitis.9 Tonzetich proposed that VSC might alter the permeability of affected cells and facilitate the transmission of

toxic metabolites into underlying connective tissue, which contributes to the progression of periodontal disease.10 Yaegaki

and Suetaka found that concentrations of VSC precursors increased with the severity of periodontal disease.5 The ratio ofCH3SH and H2S significantly increased in patients with periodontal disease in proportion to bleeding and probing depth.The amounts of H2S and CH3SH in infected periodontal pockets were considered high; however, the validity of VSC asan indicator of plaque-induced gingivitis and its relationship to oral health is still unknown.

As plaque bacteria and bacterial by-products interact with the host, inflammation and tissue destruction results, leadingto the clinical signs and symptoms of gingivitis. Gingivitis is a necessary precursor to the development of periodontitis;

however, not all gingivitis progresses to periodontitis.11 In an attempt to develop objective measures of disease activity,

studies have tested saliva, blood, plaque, and gingival crevicular fluid (GCF)10,12,13,14 Bleeding, a classic sign of inflammation,

and periodontal probing have long been used as standard measures of disease activity.13 Bleeding on probing (BOP) andthe Gingival Index (GI) have been used to clinically characterize the degree of clinical gingival inflammation; however,it is becoming increasingly apparent that traditional clinical criteria are inadequate for determining active disease sites,quantitatively monitoring the response to therapy, and/or measuring the degree of susceptibility to future breakdown. Formany years, researchers have sought refinements in the sampling of blood, saliva, plaque and GCF. The availability ofmore analytical techniques for detecting disease-associated bacteria in subgingival plaque gives significant cause for

optimism.6

Since research suggests a correlation between sulfides and plaque-induced gingivitis, the presence of sulfides in the gingival

sulcus should alert the clinician to the possibility of disease activity.11 The cytotoxicity of H2S and CH3SH strongly suggeststhat VSC may play an etiologic role in the gingival disease process 6 since both H2S and CH3SH are capable of inducing

a change in the structure of the crevicular epithelium and initiating the destructive inflammatory process.15 Rizzo indicated

that detectable hydrogen sulfide is produced in the deepest portion of periodontal pockets in humans;16 therefore, detectingthe presence or absence of VSC within the periodontal pockets could be a direct measure of the gram-negative bacterialactivity.

The Diamond Probe/Perio 2000 System™ is a device that measures sulfide levels as an adjunct to traditional diagnostictechniques in the evaluation of periodontal disease. Standard periodontal probing is a retrospective analysis of disease,whereas the Diamond Probe/Perio 2000 System provides a real-time indicator of sulfide activity. The system reducesuncertainty about the presence of gram-negative bacterial activity in the gingival sulci by detecting various forms ofsulfides (S¯, HS¯, H2S, and CH3SH). The presence of relative sulfide concentrations in individual sulcus sites alerts thepractitioner to the presence of bacterial activity, therefore improving clinical decision-making in periodontal assessment.


Researchers have studied VSC as intermediate products from the bacterial putrefaction of proteins with sulfur-containingamino acids and other proteins in the human oral cavity. Studies have demonstrated that H2S and CH3SH are predominant



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components of VSC.4,17-19 Additional studies have been conducted to determine whether or not H2S and CH3SH gases

actually do cause significant tissue destruction in the oral cavity.9,14,15,19-23

Research suggests that the presence of SUL in healthy people may be influenced by individual differences, the aging of

the plaque in the absence of oral hygiene procedures for 24 hours prior to data collection, and absorption from the diet.24

This observation is supported by the work of Yaegaki and Sanada, who found that VSC concentrations were higher in

mouth air from individuals with BOP than those with no BOP.14

Upon observing an increased volume of VSC in the oral cavity of individuals with periodontal disease, Rizzo pointed out

that H2S is one of the most toxic metabolic by-products of anaerobic bacteria located in periodontal pockets.16 In the oralcavity, the frequency of anaerobic bacteria increases in periodontitis as compared with healthy sites. Langendijk, et aldetermined that periodontal sulfate-reducing bacteria are associated with several clinical categories of periodontitis and

with periodontal sites of increased pocket depth.24 Toxic sulfide products of these strictly anaerobic bacteria can accumulatein periodontal pockets in concentrations that may cause cellular destruction. Ng and Tonzetich suggested that H2S adversely

affects protein synthesis of human gingival fibroblasts in culture.15 Upon exposure of collagen to elevated H2S concentrations,the H2S converted some acid-soluble collagen to a more soluble product. This effect on collagen solubility makes it moresusceptible to enzymatic degradation and contributes to the increased destruction of collagen observed in thoil-treated

fibroblast cultures.7

Tonzetich and McBride observed differences in intermediate sulfide metabolism between non-pathogenic strains ofBacteroides melaninogenicus var melaninogenicus (CP-) and pathogenic Bacteroides melaninogenicus (CP+)25 The CP+strains, which produced collagenase and protease and caused the formation of abscesses when injected subcutaneouslyinto the groins of guinea pigs, produced copious amounts of VSC, which consisted predominantly of CH3SH. Althoughthe CP- organisms did not grow as well as the CP+, the differences in concentration of VSC may be only partly related tothe disparity in growth rates. Results suggest that VSC analysis offers a convenient means of assessing strain differencesand pathogenic potential of Bacteroides melaninogenicus. The addition of glucose to the medium depressed total volatilesulphur production by both CP+ and CP- strains, attributable mostly to lower H2S levels.

Persson et al reported that subgingival microbiotas recovered in deep periodontal pockets had a very high capacity to

produce VSC in human serum.19 Bacterial samples taken from 7mm to 12mm periodontal pockets were incubated for

seven days to determine the amount of VSC and the degradation of serum protein produced.19 Results suggest that H2Swas the predominant VSC in the serum, but significant amounts of CH3SH also formed. In addition, members of subgingivalmicrobiotas had the capacity to degrade human serum proteins and form VSC compounds.

Persson revealed that the most potent producers of H2S were Trepomena denticola and black-pigmented species, Bacteriodesintermedius, Bacteroides loescheii, Porphyromonas endodontalis, and Porphyromonas gingivalis. Porphyromonas gingivilas

also produced copious amounts of CH3SH in serum protein,26 suggesting that VSC initiate and perpetuate an inflammatoryresponse, producing tissue irritation, bleeding, and increase of susceptibility to periodontal breakdown in the future.

Researchers have established a direct correlation between the amounts of H2S and CH3SH and the severity of periodontal

disease activity.7,14 By using radioactive, electrophoretic, and chromatographic techniques, Tonzetich and Lo observed the

reactions of H2S within saliva, collagen, and gelatin.22 The exposure of oral mucosa to both H2S and CH3SH caused amarked increase in its permeability. These findings support the involvement of sulfide compounds in the etiology ofperiodontal disease. Since H2S has been identified in periodontal pockets and is implicated in periodontal disease, resultsof the H2S treatment of collagen and saliva could provide insight into the possible mechanism of involvement in the diseaseprocess.

Periodontal pockets are believed to be one of the main production sites of oral VSC. The generation of H2S and CH3SHcould be due to the presence of the specific gram-negative organisms in gingival crevicular fluid (GCF) or the effect of



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enzymes produced by organisms in the fluid. The clinical presentation of gingivitis is important because of the association

of elevated sulfide levels and disease;6 therefore, the adjunctive use of VSC monitoring is promising.


Thirty-nine individuals, between ages 19 and 62, who were in good general health, not pregnant, free of orthodontic andprosthetic appliances, had a Gingival Index score of 0 to 1, and were free of antibiotics for one month prior to data collectionwere enrolled. Among the 39 participants, 28 (71.79%) were women and 11 (28.21%) were men with a mean group ageof 25.67 years. The informed consent approved by the Institutional Review Board of Old Dominion University was signedin duplicate, with one copy given to the individual and one copy placed on file. Participants were recruited via flyersdistributed throughout the university community and campus wide e-mail system. A single dental hygienist was calibratedfor intra-rater reliability prior to data collection.

Each participant's mandibular arch was randomized to hygiene (H) and non-hygiene (NH) sides to allow each individualto serve as his/her own control. At baseline, all participants were given the same type of soft toothbrush and fluoridetoothpaste without added ingredients for controlling gingivitis or calculus formation (Crest Regular Sodium FluorideToothpaste. Procter and Gamble, Cincinnati, OH). No attempt was made to modify participants' daily oral hygiene excepton the NH side where individuals were advised to refrain from oral care for 21 days. Participants were instructed not touse mouth rinse for the duration of the study.

A full mouth (excluding third molars) periodontal probing was performed at four sites (distofacial, facial, mesiofacial,and midlingual) to determine baseline periodontal health status. GI, BOP, and SUL scores were obtained at the same foursites at baseline and three subsequent data collection appointments over a 21-day period (days 7, 14, and 21). At thecompletion of the study, all participants were offered a prophylaxis and were followed to ensure their return to baselinegingival health status.

The Diamond Probe/Perio 2000 System is a real-time, chairside system designed to evaluate relative gram-negative bacteriain the gingival sulci and periodontal pockets (Figure 1). When sulfides are encountered in the GCF, the system providesinformation three ways: through a lighted display, by emitting an audible tone, and by providing quantitative sulfide levels.

Diamond Probe Sensor Tip® incorporates a micro-sulfide sensor into a modified "Michigan O" style disposable periodontalprobe to measure probing depth, BOP, while detecting the presence of sulfides (Figure 2). The thin, rounded probe tip has



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incremental color-coded markings at 3, 6, 8, and 11 mm for easy measurement. The tip diameter of the Diamond Probeis 0.38 mm, which is the same diameter as the "Michigan O" probe.

Various forms of sulfides (S¯, HS¯, H2S, and CH3SH) within the GCF interact with the sensor tip of the probe and generatea signal that is converted to visual and audible alerts. The sensor tip is sensitive to one part per million molar sulfide (106mol. S). The digital format displays a measurement of sulfides ranging from 0 to 10,000 units quantified in increments of0.5. Additionally, an analog display provides a four-color light bar that scales up and down to correlate with sulfideconcentrations-from green (low) to red (very high)-along with an audible tone. The Diamond Probe/Perio 2000 Systemwas used according to the manufacturer's directions.

Each of the four gingival areas (distofacial, facial, mesiofacial, and midlingual) were assigned a GI score from 0 to 3.

0=Normal gingival status

1= Mild inflammation-slight color change, slight edema. No bleeding on probing.

2= Moderate inflammation-redness, edema, and glazing. Bleeding on probing.

3= Severe inflammation-marked redness and edema, ulceration. Spontaneous bleeding.

BOP was additionally recorded as 0 (negative) or 1 (positive)

If SUL were detected, the probe tip was removed from the sulcus, washed to remove residual sulfides, and reset for thenext measurement. After completing the examination of the lingual or buccal sections of a quadrant, even without SULor BOP present, the probe tip was re-washed. This procedure was repeated when plaque from the sulcus was visible onthe probe tip.



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Results

The present study evaluated the relationship of sulfides and early dental plaque-induced gingivitis. Subsequent statisticalanalyses were conducted on average mean scores using individual teeth as the observation (or data). Data were analyzedusing the mean as the most common measure of central tendency, percentiles describing the relative position of a givenscore in relation to other scores. The Pearson correlation test was used to determine the relationship between SUL, BOP,and GI. The Wilcoxon signed rank test was used to compare the differences in mean scores in GI, BOP, and SUL betweenH and NH sides. Since no multivariate nonparametric tests were readily available for application, testing was performedfor GI, BOP, and SUL separately using the Wilcoxon signed rank statistic at the .05 level. To perform four comparisonsfor each GI, BOP, and SUL, a Bonferroni method of multiple comparisons will have a component-wise level of significanceat the 0.0125 level. Even at the p=.01 significance level, most of the conclusions remain valid.

Overall mean scores of the GI, BOP, and SUL levels are presented in Table I. Visual comparisons of mean scores arepresented in Figures 3, 4, and 5. Mean GI, BOP, and SUL scores on the NH side remained higher than on the H sidethroughout the study. GI scores on the NH side increased significantly from baseline to day 7, and then continued toincrease, peaking at day 21; whereas, GI scores on the H side remained relatively stable, increasing slightly from baselineto day 21, but lagging significantly behind the NH side throughout the study (Figure 3). BOP scores on the NH side steadilyrose from baseline to day 14, and then rapidly increased until day 21; whereas, the H side revealed no significant changesin BOP between baseline and day 7, a slight increase from day 7 to day 14, then a slight decrease to day 21 (Figure 4).SUL concentrations remained higher on the NH side throughout the study. SUL on the NH side, slowly increased frombaseline until day 7, continued to rise until day 14, then rapidly increased until day 21; whereas, SUL on H side remainedsteady from the baseline to day 7, slightly increased between day 7 and 14, then continued to increase until day 21, butlagged significantly behind scores on NH side (Figure 5).



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A comparison of the difference in mean scores of GI, BOP, and SUL are revealed in Table II. The Wilcoxon signed ranktest statistics (d) for testing the significance of the difference in mean scores and the p-values are provided. Results suggesta significant difference in GI scores between sides (p < .0001, p = .0001, p = .0001) and BOP scores (p = .011, p = .006,p = .0001) at days 7, 14, and 21, suggesting that with the progression of disease, gingival inflammation, and bleedingincreased significantly on the NH side. Data revealed a significant difference in SUL scores between sides at day 7 and21 (p=0.026, p=< .0001); however, at day 14, there was no significant difference (p= .053).



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Data were analyzed to evaluate the correlation between SUL, GI, and BOP between sides. A Pearson correlation testrevealed a moderate correlation on the NH side (r = .66, p<. 0001 and r = .61, p < .0001) and a low correlation on the Hside (r = .49, p< .0001 and r = .45, p < .0001) (Table III). Results suggest that with progression of gingivitis, there is anincrease in the strength of the positive correlation between SUL, BOP, and GI.

Discussion

Analysis revealed a statistically significant positive correlation between SUL and GI and BOP on both H and NH sides;however, the strength of the association was higher for the NH side. These results suggest that H2S in gingival crevicularfluid (GCF) increases with the severity of gingival inflammation. This finding supports the work of Solis-Graffar et al,

who found a positive correlation between the GCF volume and H2S production.17

In the present study, the increase of GI scores on the NH side at days 7, 14, and 21 represents a direct gingival responseto the continued plaque accumulations on the teeth. In addition, the significant increase of SUL on the NH side may be

due to the proliferation of gram-negative bacteria in plaque.27 Since sulfide is a metabolic by-product of proteolytic

gram-negative bacteria, increasing gram-negative bacteria would thereby increase sulphur by-products.4 Whether sulfurby-product is a direct contributor to the disease process, or merely a correlate, needs further investigation.

GI scores on the H side did not change significantly until day 21. During this study, participants reported that they focusedon their oral hygiene status and may have increased brushing and flossing time on the H side in order to compensate forplaque growth on NH side. Considering a split-mouth design was used, microbes may have been transferred from one sideto another. In addition, participants cognizant of the ever-growing plaque accumulations on the NH side reported usingtheir tongues to feel the difference between the two sides, which may have facilitated the transfer of bacteria. Althoughdata seems to suggest a significant positive correlation between SUL, GI, and BOP scores on both sides, the strength ofthe correlation was stronger for the NH side.

Current findings complement the work of researchers who first suggested the use of BOP, instead of visible inflammation,

as an objective indicator of early gingival pathology.28 Data also supports the assumption that the GI is a reliable clinicalparameter for early plaque-induced gingivitis, although transferring bacteria from one side to another may have affectedGI scores. In contrast, present findings failed to support the work of researchers that suggested that GI is remarkably

insensitive as a quantitative tool of early pathogenesis.11

Data revealed a statistically significant difference in SUL over time between the H and NH sides on days 7 and day 21;however, SUL concentrations at day 14 did not differ significantly. This data supports the work of Zhou, who found a

statistically significant difference in SUL levels at days 5-6, 8, 12-14, 15-16, and 19, but not at days 10-12.29 Both thework of Zhou and the present study demonstrated that SUL levels continued to rise throughout the experimental periodand peaked at the end of the study despite the fact that at the end of week two, SUL concentrations were not significantlydifferent between sides. Several theories may be advanced for this phenomenon. One explanation is that there is a decline



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in anaerobic activity at approximately 10-14 days of the inflammation process whereby bacteria deplete their nutrients inthe pocket. Another explanation may be related to host resistance. Perhaps around days 10-14, the strength of the hostbegins to exceed the capability of the bacteria.

Visual signs of inflammation are susceptible to subjective interpretation, can be masked by medications and smoking, and

may not reflect the true periodontal status in areas inaccessible to visual inspection.28 Therefore, monitoring SUL levelsin addition to BOP and GI may more accurately reflect real-time disease activity within the sulcus. This interpretationneeds to be validated by studying SUL levels in persons who use tobacco or take medications that may mask the clinicalsigns of inflammation. Identifying sites containing sulfides, in the absence of bleeding or visual gingival inflammation,may represent new and valuable diagnostic information.

It should be noted that data from this study suggest that SUL appear clinically at approximately the same time as BOP,but later than visible gingival inflammation. By day 21, SUL almost tripled from baseline, suggesting that SUL increasewith the progression of gingival inflammation. Additional studies are needed to support claims of SUL as a valid indicatorof early plaque-induced gingival disease and to determine how sulfide levels in the gingival sulci relate to ongoing gingivitis.The addition of microbial sampling with the evaluation of metabolic by-products of pathogenic bacteria may be oneapproach to diagnosing an active disease site.

Conclusion

Periodontal disease includes a group of inflammatory conditions of the periodontal tissue broadly categorized as gingivitisand periodontitis. Traditional clinical evaluations of the periodontium consist of an assessment of gingival inflammation,probing depth, loss of clinical attachment, bleeding on probing, and radiographic interpretation of the periodontium, whichrepresent a retrospective analysis. Therefore, more reliable real-time clinical parameters are necessary to predict earlydisease activity prior to visual changes. The ideal assessment tool should be valid, reliable, time efficient, and easily used

by clinicians.30

The purpose of this study was to evaluate the relationship between VSC and gingival health status, and to identify thecapability of VSC in detecting early plaque-induced gingivitis in the absence of clinical signs. Given the findings, thefollowing conclusions are offered:

The Diamond Probe/Perio 2000 System is able to detect sites with elevated sulfide levels.

Sulfide monitoring may be a useful real-time adjunctive indicator of early plaque-induced gingivitis.

Considering the overall design and outcome of this study, the following recommendations are made:

Increase the number and variety of participants to broaden the study population.

Include microbial sampling to monitor the presence of gram-negative anaerobic bacteria that may correlate with sulfides.

Correlate sites without bleeding and inflammation and positive sulfides.

Despite limitations of this study, the knowledge of sites with elevated sulfide levels will provide immediate feedback sothat treatment options for targeting destructive bacteria may be considered. The continued investigation of the short andlong-term relationship between sulfides and periodontal disease may enable the profession to develop a new clinicaltechnique for assessing active tissue breakdown. Such a technique would allow practitioners to intervene before visibletissue destruction has occurred; therefore, the monitoring of sulcular VSC holds promise as a new periodontal assessmenttechnique.



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Acknowledgements

This investigation was supported in part by the American Dental Hygienists' Association Institute for Oral Health, andthe Diamond General Development Corporation, Ann Arbor, MI. The authors wish to thank Debbie Z. Williams forresearch assistance.

Notes

Correspondence to: Gayle McCombs at [email protected]

References1. Page RC. Oral health status in the United States: prevalence of inflammatory periodontal diseases. J Dent Res. 1985;49: 354-367.2. Loe H, Jessen J, Theilade E. Experimental gingivitis in man. J Perio. 1965;2(4): 177-187.3. American Academy of Periodontology . The pathogenesis of periodontal disease. J Perio. 1999;70(4): 457-470.4. Persson S, Edlund MB, Claesson R, Carlsson J. The information of hydrogen sulfide and methyl mercaptan by oral bacteria. Oral

Micro Immuo. 1990;5(4): 195-201.5. Yaegaki K, Suetaka T. Periodontal disease and precursors of oral malodorous components. J Dent Health. 1989;39(7): 733-741.6. Fine DH, Mandel ID. Indicators of periodontal disease activity: an evaluation. J Clin Perio. 1986;13(5): 533-546.7. Johnson PW, Yaegaki K, Tonzetich J. Effect of volatile thiol compounds on protein metabolism by human gingival fibroblasts.

J Perio Res. 1992;27(6): 553-561.8. Morita M, Wang HL. Relationship of sulcular sulfide level to severity of periodontal disease and BANA test. J Perio. 2000;72(9):

74-78.9. Johnson PW, Tonzetich J. Sulfur uptake by types I collagen from methyl mercaptan/dimethyl disulfide air mixtures. J Dent Res.

1985;65(12): 1361-1364.10. Tonzetich J. Oral malodor: an indicator of health status and oral cleanliness. Int Dent J. 1978;28(3): 309-318.11. Van Dyke TE, Offenbacher S, Pihlstrom B, Putt MS, Trummel C. What is gingivitis? Current understanding of prevention,

treatment, measurement, pathogenesis and relation to periodontitis. J Int Acad Periodontal. 1999;1: 3-15.12. Kaldahl W, Kalkwarf K, Patil K, Molver M. Relationship of gingival bleeding, gingival suppuration, and gingival plaque attachment

loss. J Perio. 1990;61(6): 347-351.13. Lang NP, Joss A, Orsanic T, Gusberti FA, Siegrist BE. Bleeding on probing a predictor for the progression of periodontal disease?.

J Clin Perio. 1986;13(6): 590-596.14. Yaegaki K, Sanada K. Volatile sulfur compounds in mouth air from clinically healthy participants and patients with periodontal

disease. J Perio Res. 1992;27(4): 233-238.15. Ng W, Tonzetich J. Effect of hydrogen sulfide and methyl mercaptan on the permeability of oral mucosa. J Dent Res. 1984;63(7):

994-997.16. Rizzo A. The possible role of hydrogen sulfide in human periodontal disease. Hydrogen sulfide production in periodontal pockets.

Perio. 1967;5(5): 233-236.17. Solis-Graffar MC, Rustogi KN, Graffar A. Hydrogen sulfide production from crevicular fluid. Archs Oral Bio. 1980;51(10):

875-880.18. Persson S. Hydrogen sulfide and methyl mercaptan in periodontal pockets. Oral Micro Immunl. 1992;7(6): 378-379.19. Persson S, Claesson R, Carlsson J. The capacity of subgingival microbiotas to produce volatile sulfur compounds in human serum.

Oral Micro Immunl. 1989;4(3): 169-172.20. Johnson PW, Ng W, Tonzetich J. Modulation of human gingival fibroblast cell metabolism by methyl mercaptan. J Perio Res.

1992;27(5): 476-483.21. Johnson P, Yaegaki K, Tonzetich J. Effect of methyl mercaptan on synthesis and degradation of collagen. J Perio Res. 1996;31(5):

323-329.22. Tonzetich J, Lo K. Reaction of hydrogen sulphide with proteins associated with the human mouth. Archs Oral Bio. 1979;23(10):

875-880.23. Horowitz A, Folke EA. Hydrogen sulfide and periodontal disease. Periodontal Abstracts. 1972;20(2): 59-62.24. Langendijk PS, Hagemann J, Hoeven JS. Sulfate-reducing bacteria in periodontal pockets and in healthy oral sites. J Clin Perio.

1999;26(9): 596-599.25. Tonzetich J, McBride BC. Characterization of volatile sulfur production by pathogenic and non-pathogenic strains of oral

bacteroides. Archs Oral Bio. 1981;26(12): 963-969.



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26. Persson S. Hydrogen sulfide and methyl mercaptan in periodontal pockets. Oral Micro Immunl. 1992;7(6): 378-379.27. Loe H, Jessen J, Theilade E. Experimental gingivitis in man. J Perio. 1965;2(4): 177-187.28. Greenstein G, Caton J, Polson M. Histologic characteristics associated with bleeding after probing and visual signs of inflammation.

J Perio. 1981;52(8): 420-425.29. Zhou H, McCombs G, Darby M, Marinak K. Sulphur by-product: a potential indicator of early dental plaque-induced gingival

activity. J Cont Dent Prac. 2004;5(2): 029-037.30. Greenstein G. The role of bleeding upon probing in the diagnosis of periodontal disease. A literature review. J Perio. 1984;54(12):

684-688.



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The Comparative Effects of 0.12% Chlorhexidine and Herbal OralRinse on Dental Plaque-Induced Gingivitis

Elizabeth N Southern, Gayle B McCombs, S Lynn Tolle and Ken Marinak

Purpose. The purpose of this study was to determine the effects of two oral rinses-one 0.12% chlorhexidine rinse (CHX)and one herbal rinse (HBR)-on gingival health status over time.

Methods. Sixty-three participants were randomly assigned to one of three treatment groups: CHX, HBR, or placebo.For three months, participants rinsed twice daily (morning and evening) with ½ ounce of allocated rinse after brushingand flossing. Individuals were given the same type of soft bristle toothbrush and whitening toothpaste. No attempt wasmade to modify participants' routine oral care, except they were advised to refrain from use of any other oral rinse forthe duration of the study. Data were collected at baseline (B), month one (1), two (2), and three (3) utilizing the GingivalIndex (GI), Plaque Index (PI), and bleeding on probing (BOP). A full mouth periodontal probing was performed atbaseline and at the completion of the study. A soft tissue oral assessment was completed at each visit. CHX, HBR, andplacebo data were compared between three time intervals, B-1, B-2, and B-3. Statistical analysis was conducted bymeans of multiple regression using generalized linear models. Paired comparison tests - ANOVA followed by a posthoc Tukey test - were used to confirm results.

Results. CHX was the only oral rinse to demonstrate a statistically significant effect on the reduction of mean GI, BOP,and PI scores when compared to placebo. CHX demonstrated a 31% reduction in the proportion of GI scores betweenB-2 and a 29% reduction between B-3 (p=.003 and p=.012, respectively). CHX demonstrated a 19% reduction of BOPsites between B-1, 32% reduction between B-2, and 29% reduction between B-3 (p=.028, p=.000, and p=.005, respectively).CHX demonstrated a 20% reduction in PI scores between B-1, and a 28% reduction between B-2 (p=.005 and p=.032,respectively). The effects of HBR on reducing mean GI, BOP, and PI scores were not statistically greater than placeboat any time during the study.

Keywords: Dental plaque, gingivitis, chlorhexidine, oral rinse, herbal, mouthrinse

Introduction

Bacterial plaque is the primary etiological cause of chronic gingivitis.1 Many patients, due to difficulty maintaining thorough

oral hygiene, accumulate significant amounts of bacterial plaque containing virulent pathogens.2 Effective oral care isimportant for all individuals; it is especially important for those who are compromised due to poor dexterity, an immunesystem deficiency, and/or are undergoing chemotherapeutic or radiation therapy. Despite one's best efforts, mechanical

aids may fail to adequately remove plaque biofilm or "reduce the bacteria below the patient's threshold for disease."3 Forthese individuals, a therapeutic mouthrinse is often recommended as an adjunct to mechanical plaque control to helpmaintain gingival health.

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A variety of oral rinses are available to consumers either by prescription (Rx) or over-the-counter (OTC). The increasingpopularity of herbal or "natural" products has led companies to include these in their oral care product lines. Since herbalproducts may be purchased OTC, they have attracted millions of consumers who are looking for an alternative mouthrinse;however, more research is needed to determine the effectiveness and safety of these products.

To date, little research has been conducted on the comparative effects of 0.12% chlorhexidine versus herbal mouthrinseson plaque-induced gingivitis and plaque biofilm accumulations. The body of evidence pertaining to herbal products issmall; therefore, tests should be conducted to gain evidence regarding their effectiveness and safety and to substantiate

product claims.3 Fischman concluded that mouthrinse sales are closely related to whether a consumer likes the taste, smell,

or color, and whether the consumer feels like the product leaves their mouth feeling fresh and clean.4 Depending on theeffectiveness of the ingredients and patient compliance, evidence suggests that mouthrinses may act as beneficial adjunctive

aids, especially for those who do not achieve optimal plaque control.5,6


Current research indicates that plaque biofilm, a complex three-dimensional arrangement of bacteria in a self-sustaining

community, has been associated with the initiation and progression of gingivitis and the onset of periodontitis.1,7 Van Dykedefined gingivitis as the "marginal inflammation of the gingiva comprising an inflammatory cell infiltrate, reversible

destruction of collagen, and the clinical appearance of redness and swelling."1 Plaque-induced gingivitis begins at thegingival margin, and the virulent pathogens can progress throughout the gingival unit.8 Irreversible damage may occur

when microbes migrate deeper into the epithelium.9 Antimicrobial agents may aid in disrupting pathogenic bacteria

associated with plaque, thus aiding in the control of gingivitis.10 Healthy oral flora is influenced by effective plaque control;however, the pathogenic degree of the bacteria in plaque also plays a significant role, as does the host response, immune

status, and amount of time that plaque remains on the tooth.11 Local and systemic factors should also be considered whenaddressing the host response in reducing the virulence of plaque biofilm since this interaction has the potential to exacerbatethe gingival disease process.

Kornman states that there are three ways to treat or prevent gingivitis: 1) elimination of all clinically detectable plaque;2) reduction of plaque below the individual's threshold for disease; and/or 3) alteration of the microbial succession insupragingival plaque.10 However, the depth that a mouthrinse effectively penetrates into a periodontal pocket of 1-6 mmis approximately 21% of the total pocket depth; therefore, the adjunctive use of a therapeutic oral rinse will best aid in

altering the bacteria in subgingival plaque in individuals with gingivitis rather than periodontitis.12

The present study focused on two specific mouthrinses: OTC herbal rinse (HBR) and 0.12% chlorhexidine rinse (CHX),both claiming to be effective in the treatment of gingivitis. Chlorhexidine (0.12%) has the American Dental Association(ADA) Seal of Acceptance and is Food and Drug Administration (FDA) approved for the reduction of plaque and gingivitis.Chlorhexidine also has long-standing research to substantiate its safety 13-16 and efficacy whereas the HBR mouthrinse

used in this study is a newer, less researched product.3,17,18

Many studies have been conducted on 0.12% chlorhexidine mouthrinses; 14,16,19-27 however, little research has been conducted

to determine the efficacy of herbal mouthrinses and their ability to control plaque-induced gingivitis.18,28,29-31 Despitecommonly known side effects such as temporary loss of taste; staining of the teeth, restorations, and mucosa; dry, soremucosa; bitter taste; and a slight increase in supragingival calculus formation, CHX is considered the "gold standard" of

antimicrobial rinses because of broad-spectrum antibacterial activity3 and substantivity of 8-12 hours. Chlorhexidinecontains 11.6% alcohol, whereas the HBR tested in this study is a non-alcoholic, sugar-free product. In certain individualswhose oral health is compromised, or are recovering alcoholics, the addition of an effective therapeutic herbal oral rinsemay be a valuable adjunct to brushing and flossing. Cost and accessibility are additional factors to be considered whenselecting the appropriate oral rinse. The HBR and CHX mouthrinses used in this study were similar in price and quantity,



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although the CHX product can only be obtained by prescription. Presently, the HBR oral rinse sells at a major pharmacychain for $6.79 (8 oz) and the CHX product retails for approximately $15.00 (16 oz).

The manufacturer of the HBR product evaluated in this study claims it does not contribute to staining, tartar buildup, ortaste alteration; possesses the ability to kill germs as effectively as the leading CHX prescription mouthrinse; and reduces

gingivitis.32 The ingredients in the HBR include filtered spring water, vegetable glycerin, echinacea, goldenseal, calendula,aloe, bloodroot, grapefruit seed extract, citric acid, spearmint oil, peppermint oil, and cinnamon. Therapeutic benefits fromthese ingredients have not been extensively tested in a clinical setting. However, research conducted by Kaim et al suggests

that HBR has an antimicrobial effect against A. viscosus and S. mutans in vitro.28 Additional research conducted by Scherer

et al demonstrated HBR reduced gingival bleeding after three months of use as compared to placebo.18


The protocol was reviewed and approved by the Old Dominion University Institutional Review Board. Qualifyingparticipants signed informed consent, in duplicate, with one copy given to the participant and the other retained. Sixty-threeindividualss were recruited via flyers and campus emails. Individuals who met the following inclusion criteria wereenrolled: GI score of 2 or 3, 18 years of age or older, and in general good health. Potential participants were excluded ifthey presented with advanced periodontal disease (AAP IV or greater), history of antibiotic use in the last 90 days, needfor antibiotic pre-medication, or anterior facial restorations; used a daily anti-gingivitis rinse within the last 3 months;were pregnant, a smoker, or not in good general health. Participants were randomized to one of three product groups (CHX,HBR, or placebo). Individuals were identified by code numbers throughout the study.

At each appointment, the health history was reviewed and a soft tissue oral examination was performed. At the conclusionof the study, participants were evaluated for the need of a dental prophylaxis. This service was provided to participantswho exhibited staining or calculus deposits attributed to the use of the study product.

A randomized design was utilized over a three-month period to evaluate the effects of 0.12% CHX, HBR, and placebomouthrinses on gingival health and plaque accumulation. Information from product literature and previous studies suggestthat the time period for initial treatment of a patient undergoing 0.12% CHX mouthrinse therapy should be limited to three

months; then, the individuals' gingival health status should be reevaluated.33 Numerous gingivitis studies have been

conducted using an experimental period of three months or less; 15,16,18,20-31 therefore, a three month study design was usedfor this study.

Data collection:

Baseline: Oral Exam (OE), Plaque Index (PI), Gingival Index (GI), Bleeding On Probing (BOP), and Probing PocketDepth (PPD)

Month 1: OE, PI, GI, and BOP

Month 2: OE, PI, GI, and BOP

Month 3: OE, PI, GI, BOP, and PPD

In an attempt to replicate "real life" comparison group,s where a majority of consumers who purchase mouthrinse productshave no recent history of a dental prophylaxis, no prophylaxis was conducted prior to study initiation. At baseline,participants were randomly assigned to one of three treatment groups: Group I (placebo), Group II (HBR), and Group III(0.12% CHX). All individuals were given the same type of soft toothbrush (Crest Complete, Procter and Gamble Co. Inc.,Cincinnati, OH) and fluoride whitening toothpaste (Crest Dual Action Whitening Cool Mint, Procter and Gamble, Co.,Inc. Cincinnati, OH) to decrease the possible side effects of staining and lessen examiner bias. Participants were instructedto use the assigned mouthrinse in conjunction to their normal oral hygiene routine. Product identifiers were removed fromall containers. No attempt was made to modify participants' regular daily oral hygiene routine except they were advisednot to use any other oral rinse for the duration of the study. Standardized written and oral rinsing instructions were provided



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at baseline and reviewed at each visit. Participants received periodic telephone calls to encourage protocol complianceand retention.

Data were collected using three periodontal assessment tools to assess gingival inflammation (GI), plaque accumulations(PI), and bleeding (BOP). A full mouth periodontal probing was performed at six sites per tooth (mesiofacial, facial,distofacial, mesiolingual, lingual, and distolingual) at baseline and at the end of the study using UNC-12 periodontal probes(Hu-Friedy Manufacturing Co., Inc., Chicago, Il). GI, BOP, and PI scores were obtained from the same six sites. Theexaminer and participants were blinded to product allocation. A single calibrated dental hygienist was used to collect alldata. A research assistant was responsible for product allocation and supervising rinsing procedures. New products weredispensed at each appointment in unmarked bags and unused product was collected.

The Plaque Index (PI) was used to measure plaque accumulation. A score of 0-3 was assigned to six sites per tooth using

the following criteria:34

0 = No plaque on gingival margin.

1 = A film of plaque is supragingival, and adheres to the free gingival.

2 = Moderate plaque is present supragingivally and subgingivally.

3 = Heavy plaque is present supragingivally and subgingivally.

The Gingival Index (GI) was used to determine severity and location of gingivitis. A score from 0-3 was assigned to six

sites per tooth, using the following criteria:35

0 = Normal gingiva. Pale pink color, normal stippling, gingiva firm when probed. Gingival margin located on enamel orapical to CEJ.

1 = Mild inflammation. Slight changes in color of gingiva- more reddish than normal, slight edema. No bleeding onprobing.

2 = Moderate inflammation. Gingiva is red to reddish-blue with moderate edema present and glazing. Bleeding on probingis present.

3 = Severe inflammation. Marked redness, edema, and ulceration. Tendency towards spontaneous bleeding.

Greenstein stated that bleeding on probing is an objective way to assess for clinical, bacteriologic, and histopathologicchanges, since bleeding indicates areas infiltrated by inflammatory cells and histopathologic alterations due to the epithelial

proliferation that occurs in early to established gingival lesions.36 Therefore, in the present study, BOP was independentlyscored as positive when bleeding was detected after 15 seconds, when stimulated by a periodontal probe.

Statistical Analysis

Statistical analysis was conducted by means of multiple regression using generalized linear models to analyze the paireddifference between baseline and month one (B-1), month two (B-2), and month three (B-3). CHX and HBR were comparedto placebo. Paired comparison tests, ANOVA followed by a post hoc Tukey test, were used to confirm the results. Datasets included continuous proportional data and ordinal data. Comparing the paired difference in proportion allowedparticipants to act as their own control. Change in proportion was calculated by subtracting the baseline proportion ofunhealthy observations from the proportion of unhealthy observations following allotted months of rinsing. A negativevalue indicates that the proportion of scores decreased. Predictors of demographic data were analyzed separately.Pre-statistical analysis determined that age and race had an influence on GI scores; therefore, these factors were controlledfor in the final data analysis. Age and race exhibited no statistically significant influence on PI or BOP. The p level wasset at <0.05, a 95% confidence level, to minimize Type I error.



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Results and Discussion

Sixty-three participants, 57% male (n=35) and 43% female (n=28) with a mean age of 25 years (sd=7.67), of whom 61%were Caucasian, 27% Asian, and 12% African American, were enrolled. During the course of the study, one subjectwithdrew from each group due to personal reasons, resulting in a final sample size of 60 (30 in each group).

Gingival Health (GI)

Randomization produced similar equivalent baseline groups that exhibited overall GI scores of 2 or 3. Analysis of GIscores indicate that CHX exhibited a statistically significant reduction when compared to placebo in the proportion ofmean GI scores at B-2 and B-3 (p= .003 and .012, respectively) (Table I). These data support the work of Grossman who

found a 29% reduction of gingival bleeding following three-month use of CHX.37 HBR did not reveal a statisticallysignificant reduction greater than placebo in the proportion of GI scores at any time during the study. This is a conflictingcomparison to the results by Scherer et al that indicated a 26.9 % reduction in gingivitis following rinsing with HBR for

three months.18

The greatest significant decrease in the proportion of GI scores, occurred in the CHX group from B-2 as indicated by a31% reduction. One explanation for this comparison may be examiner bias; on the other hand, participants may have beenenthusiastic about the study, resulting in greater compliance to rinsing regimens, which decreased as the study progressed.

Bleeding (BOP)

CHX exhibited a statistically significant reduction in BOP greater than placebo throughout the study as indicated by thedecrease in proportion of positive bleeding sites between B-1, B-2, and B-3 (p=.028, .001, and .005, respectively) (TableII). HBR did not have a statistically significant effect greater the than placebo on decreasing positive bleeding sites at anypoint in the study. CHX showed a comparable 29% reduction of both BOP and GI scores at B-3, which is expected sincebleeding and gingival inflammation are reflected in GI scores. Ultimately, CHX was the only mouthrinse that demonstrateda statistically significant effect on the reduction of bleeding when compared to placebo.



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In the present study, BOP data suggest that CHX had significant clinical effects on the improvement of gingival health.Over time, CHX effectively reduced clinical evidence of gingivitis as indicated by a statistically significant reduction inGI and BOP scores. The greatest decrease in BOP was evident from B-2 in the CHX group as indicated by a 32% decreasein positive bleeding sites.

Plaque (PI)

Only CHX had a statistically significant effect greater than placebo on reducing the proportion of PI scores of 2 or 3 (TableIII). CHX demonstrated a 20% reduction in PI scores between B-1, and a 28% reduction between B-2 (p=.005 and .032,respectively). Although the CHX group demonstrated a 28% decrease in PI scores from B-3 (p= 0.098), this reductionwas not significantly different from placebo. HBR did not have a statistically significant effect greater than placebo ondecreasing the proportion of PI scores at any time during the study.



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In the majority of cases, participants were examined at the same time of day to reduce extraneous variables in plaqueaccumulation, such as the length of time between home care and data collection. Variations in plaque accumulations mayhave been influenced by the Hawthorne effect or the tendency of participants to improve behavior because of the expectationscreated by the situation. On the other hand, as the study progressed, participants may have become more lax with theiroral care resulting in an increase of PI scores.

Probing Pocket Depth (PPD)

Full mouth periodontal probing measurements were obtained at baseline and month three (B-3). Statistical analysis showedno statistically significant change in PPD in any of the groups.

Summary and Conclusions

The purpose of this study was to determine the comparative effects of 0.12% CHX and HBR to placebo on gingival healthand plaque biofilm accumulations over time. The ability of an oral rinse to be retained in the oral cavity and maintainpotency over an extended length of time has been debated. Lang stated that the substantivity of an antimicrobial agent

needs sufficient contact time with a microorganism in order to inhibit or kill it.34 Chlorhexidine, with a substantivity of8-12 hours, is considered to be highly effective; whereas, the substantivity of the HBR is unknown. Conclusions from thepresent study suggest that CHX was effective in killing virulent bacteria found in plaque biofilm, and is evident by astatistically significant reduction in the proportion of GI scores and BOP sites in the CHX group. The greatest significantdecrease in the proportion of GI scores occurred in the CHX group between B-2 as indicated by a 31% reduction. Thereis not enough statistically significant evidence to suggest that HBR had a greater effect in reducing GI scores than placebo.During the study, extraneous variables such as length of study and busy schedules may have reduced participants' enthusiasm,resulting in less compliance to rinsing regimens, or perhaps participants who enrolled with minimal gingivitis may haveexhibited healthier gingival status over less time.



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Results indicate that CHX had a statistically significant effect on decreasing the paired difference in the proportion ofBOP sites compared to placebo, as indicated by the decrease in positive BOP scores between B-1, B-2, and B-3. Thegreatest significant decrease in BOP sites was evident in the CHX group between B-2 as indicated by 31% reduction.There is not enough statistically significant evidence to suggest that HBR is more effective than placebo in its ability toreduce BOP over time.

The results of this study indicate that only CHX had a significant effect on decreasing moderate to heavy plaque at B-1and B-2 when compared to placebo. Although the greatest reduction in PI scores occurred between B-3 for CHX, theresults were not statistically different than placebo. The largest significant decrease in plaque scores occurred in the CHXgroup between B-2 as indicated by a 28% decrease in the proportion of PI scores. A 16% reduction of PI scores betweenB-3 in the placebo group may be due to the Hawthorne effect as participants reached the end of the study. There was nostatistically significant decrease in PI scores in the HBR group when compared to placebo at any time during the study.

Little research has been conducted on the comparative effects of herbal oral rinses and chlorhexidine oral rinses. With theproliferation of herbal oral care products, it is important for clinicians to make evidence-based decisions when makingproduct recommendations. Research by Kaim et al suggests that there are certain ingredients in herbal oral rinses that

exhibit evidence of anti-inflammatory and anti-fungal therapeutic effects.28 These components include echinacea, goldenseal,and grapefruit seed extract. However, research needs to be conducted to determine the substantivity of HBR, as well asdetermine its antimicrobial effects on gingivitis, plaque biofilm accumulation, and related bacteria.

Based on the results of this study, it is important to note that 0.12% CHX mouthrinse effectively reduced the clinicalsymptoms of plaque-induced gingivitis, and had a statistically significant effect on the reduction of plaque scores. Datafrom this study suggests that CHX is more effective than HBR in reducing clinical indicators of gingivitis when comparedto placebo. Data does not support HBR product claims suggesting that it is as effective as CHX. Therefore, individualswho are looking for a "natural," sugar-free, non-alcohol mouthrinse should be advised that there is little research to supportthe effectiveness of herbal oral rinses. Dental professionals will benefit from this body of evidence as they seek to makeevidence-based product recommendations.

Suggestions for future studies include: (1) address the substantivity of HBR mouthrinses; (2) incorporate microbial analysisin order to draw conclusions about antibacterial effects; (3) expand study population to include broader disease status andvaried age groups; (4) extend study to six months; (5) add stain and calculus indices, (6) increase internal validity bysupervising rinsing; and (7) determine if the whitening toothpaste interacted with components of the mouthrinse.

Acknowledgements

Researchers are grateful to Russell Bogacki, DDS, MS, assistant professor at Virginia Commonwealth UniversitySchool of Dentistry for statistical support and Deborah Z. Williams for research assistance.

Notes

Correspondence to: Gayle McCombs at [email protected]

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treatment, measurement, pathogenesis and relation to periodontitis. J Int Acad Periodontal. 1999;1: 3-15.2. Mandel I. Antimicrobial Mouthrinses: Overview and Update. JADA . 1994;Suppl125: 2S-10S.3. Lyle D. The Role of Pharmacotherapeutics in the Reduction of Plaque and Gingivitis. J Prac Hyg. 2000;Suppl9(6): 46-50.4. Fischman S. The History of the Oral Hygiene Products: How Far Have We Come in 6000 Years?. Periodontology 2000. 1997;15(7):

14.5. DeVore L. The Rinse Cycle. RDH. 2002;22(9): 82-93.



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6. Ciancio S. Formulating Plaque Reduction. Dimen Dent Hyg. 2004;2(11): 24-28.7. Walker C, Karpinia K, Baehni P. Chemotherapuetic Agents and Other Antimicrobials. Periodontology 2000. 2004; 146-165.8. Mariotti A. Dental Plaque -Induced Gingival Disease. Ann Perio. 1999;4(1): 17-7.9. Research, Science, and Therapy Committee of The American Academy of Periodontology. Informational Paper. The Pathogenesis

of Periodontal Diseases. 1999;70: 457-470.10. Kornman K. The Role of Antimicrobials in the Prevention and Treatment of Periodontal Disease. . In: In Perspectives of Oral

Antimicrobial Therapuetics. Littleton, MA: The American Academy of Periodontology; 1987. 37- 46.11. Schenkein H. The Pathogenesis of Periodontal Disease. J Perio. 1999;70: 457-470.12. Braun RE, Ciancio SG. Subgingival Delivery by an Oral Irrigation Device. J Perio. 1992;63(5): 469-472.13. Adams D, Addy M. Mouthrinses. Adv Dent Res. 1994;8(2): 291-301.14. Beiswanger B, Mallat M, Jackson R, Mau M, Farah C, Bosma M, Bollmer B, Hancock E. Clinical Effects of a 0.12% Chlorhexidine

Rinse as an Adjunct to Scaling and Root Planing. J Clin Dent. 1992;3(2): 33-38.15. Mandel I. The Mouthrinse Wars. J Perio. 1989;60(8): 478-480.16. Segreto V, Collins E, Beiswanger M, Rosa M, Isaacs R, Lang N, Mallatt M, Meckel A. A Comparison of Mouthrinses Containing

Two Concentrations of Chlorhexidine. J Perio Res. 1986. Suppl; 23-32.17. Ciancio S. Pharmacology of Oral Antimicrobials. . In: Perspectives on Oral Antimicrobial Therapuetics. Littleton (MA): American

Academy of Periodontology; 1987. 25- 35.18. Scherer W, Gultz J, Sangwoo Lee s, Kaim J. The Ability of an Herbal Mouthrinse to Reduce Gingival Bleeding. J Clin Dent.

1998;9(2): 97-100.19. Grundemann L, Timmerman M, Ijserman Y, van der Veldon U, van der Weigden GA. Stain, Plaque and Gingivitis Reduction by

Combining Chlorhexidine and Peroxyborate. J Clin Perio. 2000;27: 9-15.20. Ernst C-P, Prockl K, Willershausen B. The Effectiveness and Side Effects of 0.1% and 0.2% Chlorhexidine Mouthrinses: A

Clinical Study. Quintes Intl. 1998;29(7): 443-448.21. Eldridge K, Finnie S, Stephens J, Mauad A, Munoz C, Kettering J. Efficacy of an Alcohol-Free Chlorhexidine Mouthrinse as an

Antimicrobial Agent. J Pros Dent. 1998;80(issue): 685-690.22. Corbet E, Tam J, Zee K, Wong M, Lo E, Mombelli A, Lang N. Therapeutic Effects of Supervised Chlorhexidine Rinses on

Untreated Gingivitis. Oral Disease. 1997;3: 9-18.23. Eaton K, Rimini F, Zak E, Brookman D, Hopkins L, Cannell P, Yates L, Morrice C, Lall B, Newman H. The Effects of a 0.12%

Chlorhexidine-Digluconate-Containing Mouthrinse Versus a Placebo on Plaque and Gingival Inflammation Over a 3-MonthPeriod. J Clin Perio. 1997;24: 189-197.

24. Joyston-Bechel S, Hernaman N. The Effect of a Mouthrinse Containing Chlorhexidine and Fluoride on Plaque and GingivalBleeding. J Clin Perio. 1993;20: 49-53.

25. Jenkins S, Addy M, Newcomb R. Evaluation of a Mouthrinse Containing Chlorhexidine and Fluoride as an Adjunct to OralHygiene. J Clin Perio. 1993;20: 20-25.

26. Renton-Harper P, Addy M, Moran J, Doherty F, Newcombe R. A Comparison of Chlorhexidine, Cetylpyridinium Chloride,Triclosan, and C31G Mouthrinse Products for Plaque Inhibition. J Clin Perio. 1996;67(5): 486-489.

27. Brightman L, Terezhalmy G, Greenwell H, Jacobs M, Enlow D. The Effects of a 0.12% Chlorhexidine Gluconate Mouthrinse onOrthodontic Patients Aged 11 Through 17 With Established Gingivitis. Am J Orthod Dentofacil Ortho. 1991;100(4): 324-329.

28. Kaim J, Gultz J, Do L, Scherer W. An In Vitro Investigation of the Antimicrobial Activity of an Herbal Mouthrinse. J Clin Dent.1998;9: 46-48.

29. Van der Weijden G, Timmer D, Timmerman M, Reijerse E, Mantel M, Vander Velden U. The Effect of Herbal Extract in anExperimental Mouthrinse on Established Plaque and Gingivitis. J Clin Perio. 1998;25: 399-403.

30. Gultz J, Kaim J, DeLeo J, Scherer W. An In Vivo Comparison of the Antimicrobial Activities of Three Mouthrinses. J Clin Den.1998;9(2): 43-45.

31. Serfaty R, Itic J. Comparative Clinical Trial with Natural Herbal Mouthwash Versus Chlorhexidine in Gingivitis. J Clin Den.1988;Suppl 1: 34-37.

32. The Natural Dentist [homepage on the Internet]. Englewood Cliffs (NJ): The Natural Dentist ; [cited 2001 Sep 11]. Availablefrom: http://www.thenaturaldentist.com.

33. Peridex Oral Rinse, Chlorhexidine Gluconate 0.12% Antigingivitis Oral Rinse, Product Monograph.. Phoenix (AZ): Zila; 1998.34. Silness J, Loe H. Periodontal Disease in Pregnancy II. Correlation Between Oral Hygiene and Periodontal Conditions. Acta Odont

Scand. 1964;22(1): 121-135.35. Loe H. The Gingival Index, the Plaque Index, and the Retention Index Systems. J Perio. 1967;38: 610-616.36. Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease. J Perio. 1984;54(12): 684-688.37. Grossman E, Reiter G, Sturzenberger O, De La Rosa M, Dickinson T, Ferretti G, Ludlam F, Meckel A. Six Month Study of the

Effects of a 0.12% Chlorhexidine Mouthrinse on Gingivitis in Adults. J Perio Res. 1986. Suppl 21: 33-34.



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Copyright by the American Dental Hygenists Association

Faith-Based Initiatives and Service-Learning: A Match Made inHeaven

Sherri M Lukes and Faith Y Miller

Southern Illinois University, Carbondale

Service-learning opportunities can provide students with excellent multicultural, applied experiences, while providingmuch-needed services to underserved populations. In an age of shrinking budgets, partnering faith-based organizationsand educational institutions creates an avenue for positively impacting access to care for these populations. A dentalhygiene faculty member and six dental hygiene students incorporated preventive dental services into a constructionmission trip to Tamaulipas, Mexico. Dental services included periodontal debridement, routine prophylaxes, dentalsealants, and fluoride varnish applications. Services were provided with portable dental equipment for both adults andchildren in a church in Palmillos, and under a canopy in the village of La Mula. Informed consent for treatment wasobtained. Twenty-three adults and 38 children were served in the two villages. The dental hygiene students receivedinternship hours for a rural health and geriatrics course, as part of a baccalaureate-degree dental hygiene curriculum.Further, students participated in a sealant grant program and mouthguard project. Area church leaders offered afacility in which to provide services from both programs to children within the predominately African Americancommunity near the university. Consent forms were obtained from churches, allowing children to receive servicesduring a church-sponsored summer lunch program and vacation Bible school. Dentists, dental hygiene and dentaltechnology faculty, and dental hygiene students participated in both the sealant and mouthguard programs. A total of45 children received care; all received exams, and 80 sealants were placed. Thirteen children received sport mouthguardsand three received bruxism appliances. Reflective writing about all of the service-learning experiences is used forprogram evaluation. All students deemed these service-learning experiences as a very beneficial component of theireducational experience.

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Project to Research Alternatives for Dental Health EducationPrograms

Heidi Philley

Mohawk Valley Dental Hygiene Association; Oneida-Madison County Dental Coalition

The program purpose was to expand access to dental health education in central New York, where there is a need tofind alternative ways to raise oral health awareness among children and their families. The Oneida-Madison CountyDental Coalition fulfills the objectives of a preventive dentistry grant for high-risk children. One objective is to educatechildren and families about the importance of good oral health habits. The coalition partnered with the Mohawk ValleyDental Hygienists' Association (MVDHA) and with the Mid-York Library System to develop "Dental Health StoryBoxes." Each story box includes books about teeth and dental visits, a puppet and toothbrush, and a resource bookwith activity sheets. The library system sends out periodic broadcasts with information about the Dental Health StoryBoxes to its 44 public libraries. The libraries request the boxes for interested individuals. Anyone can feel confident ofa successful program using the outline and contents of the Dental Health Story Box. Evaluation is done by the individualsat the 44 libraries using this educational tool, and they are reviewed regularly. The evaluation form asks for numbersof users and their ages, and comments on books, resource materials, and puppets. There has been positive responsefrom those using the story boxes (an evaluation sheet is included) each time the boxes go out. This year they have goneout over 120 times. Dental hygienists have favorably reviewed the Dental Health Story Box at the local and state level.Many have requested information on how to duplicate it in their areas. There is dental health education sustainabilityin having a Dental Health Story Box available for the public library. MVDHA has oversight on the project and plansto continue and evaluate the project on a yearly basis.

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A Collaborative Education Program in Dental Assisting, DentalHygiene, and Postgraduate General Dentistry

Constance Gore, Donna Solovan-Gleason, Krista Schobert, Thomas Porter and Shannon Johnson

Traditionally, the education of dental assistants, dental hygienists, and general dentistry residents takes place in separateclinic areas and in separate curriculums with limited or no interaction among the disciplines. In contrast, dentalassistants, dental hygienists, and dentists are expected to practice in a cohesive and efficient manner upon graduation.Recognizing this as a problem, a facility was designed and built to integrate the dental assisting and dental hygieneprograms with the general dentistry residency program for didactic and clinical education. The students are educatedin the team concept of providing patient care. The clinic facility is modeled on a private practice office with a commonreception area; the dental hygiene treatment area is immediately adjacent to the dental resident operatories. Dentalassisting students assist in the dental hygiene and resident operatories. Each dental hygiene student, dental assistingstudent, and dental resident is grouped into a treatment team. Patient treatment is planned and coordinated by the teamwith faculty supervision. Responsibilities of dental hygiene students include the patient's initial periodontal therapy,oral hygiene instruction, post-surgical management, and post-care maintenance. Dental assisting students providechairside assisting for dental hygiene students and residents, schedule appointments, and monitor patients' progressthrough treatment. Dental residents are team leaders and are responsible for providing patient treatment and monitoringthe dental hygiene and dental assisting students. Meetings provide the members and the supervising faculty theopportunity to review each patient's progress. All team members participate in case presentation seminars. Thiscollaborative program is a work in progress to determine the educational value of having dental hygiene, dental assisting,and general dentistry residents train together in preparation for the team concept of providing care. Evaluation of theprogram will be done through conventional assessment processes to include review of national and clinical board examscores to compare student scores to those of other dental hygiene and dental assisting schools, and the review of graduatestudent and employer surveys to determine if students are judged better prepared to enter the workforce.

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Estimating the Cost Savings of a Targeted Sealant Program inColorado

Joan O'Connell, Diane K Brunson and Theresa Anselmo

Dental sealants have been shown to be effective in preventing caries in permanent molars. Targeting schools for sealantsbased on free and reduced-cost lunch participation has been shown to be cost-effective. Estimating the cost, includingpersonnel, portable units, and disposable supplies, to meet the Healthy People 2010 objective for sealants in Coloradowas undertaken. This information would be used to provide state policy makers with information to set priorities fororal health prevention strategies. Utilizing data from the Colorado Chopper Topper school-based sealant program,which serves the five-county Metro Denver Area, the average program costs were determined. The Chopper Topperprogram is estimated to serve 32% of eligible schools and 1,500 children in the target area yearly. In 2002, the prevalenceof dental sealants in first permanent molars among third graders in Colorado was determined using a conveniencesample of 19 counties and estimating the prevalence of sealants statewide. Twenty-nine percent of third graders werefound to have at least one sealant, significantly less than the desired Healthy People 2010 objective and Maternal ChildHealth National Oral Health performance measure. By analyzing these data, the overall dental utilization rates andrestoration sequelae over a lifetime obtained from Delta Dental Plan of Colorado, and the societal costs of lostproductivity, the cost savings of averted caries through the expansion of the Chopper Topper Sealant Program, byinitiating similar programs throughout the state, was projected. The results indicate that the state could easily be dividedinto target regions served by teams of dental hygienists who would, in most cases, share portable dental units and servesecond-grade children in all 276 eligible elementary schools. If all targeted schools agreed to participate and 85% ofchildren received sealants, the percentage of Colorado third graders with at least one sealant would exceed the HealthyPeople 2010 objective of 50%.

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Value of a National Board Dental Hygiene Review Course: ANational Survey

Chris French Beatty, David D Marshall and Heather O Mapp

Funding for this project was provided by Dental Hygiene Seminars, Inc.

A variety of National Board Dental Hygiene (NBDH) review courses are available to dental hygiene students. Thesecourses are highly publicized and costly. Dental hygiene educators are called on to recommend the appropriateness ofreview courses. The purpose of this study was to evaluate the value of a nationally based NBDH review course offeredby Dental Hygiene Seminars, Inc., in various locations across the United States. After institutional review board approvalby Texas Woman's University, a questionnaire was mailed to 1,648 individuals who had attended the course in 2002.The mailing labels were procured from the course directors. Questions on the questionnaire related to students' yearof graduation, type of dental hygiene program, grade-point average (GPA), English as a Second Language (ESL) status,number of attempts required to pass the NBDH, passing score on NBDH, the materials they used to study for theexamination, factors that influenced their decision to attend this course, relevance of the course to the NBDH, valueof the course, factors that made the course beneficial, and willingness to recommend the course. Of the 1,648questionnaires mailed, 156 were returned as undeliverable. Of the remaining 1,492 questionnaires, 439 were returnedfor a 29% response rate without a follow-up mailing. All data were self-reported. The data will be analyzed with StatisticalPackage for Social Scientists software (Chicago, IL) to figure counts and percentages. Also, correlations and multipleregression will be run to analyze the relationship of performance on the NBDH and perceived value of the course withvarious factors, including year of graduation, type of program attended, GPA, ESL status, number of attempts requiredto pass the NBDH, and materials used to study for the examination.

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Oral Health Care Practices and Perceptions Among Nursing HomeResidents: A Case Study

Bridget M Boyce, Christina B DeBiase, Nancy L Adams and Mary W Carter

Purpose. Currently, little knowledge exists about the extent to which: 1) nursing home residents perceive their oralhealth care as being adequate, 2) nursing home residents' perceptions and actual oral health status are congruent, and3) oral health care outcomes and residents' perceptions of their own oral health care are influenced by levels of physicalfunctioning. The purpose of this study was to evaluate the oral health practices and perceptions of oral health careamong cognitively intact nursing home residents.

Methods and Materials. Institutional review board approval was obtained, and a modified, one-shot case study design,*a 20-question resident interview, and a 10-category oral health care evaluation were utilized in three encounters withthe accepting sample of 10 West Virginia nursing home residents. The interview identified each participant's currentand past oral health care practices, perceptions about their current oral practices, and levels of need and functioningin the nursing home. The evaluation assessed the current oral health status of the participants. A licensed West Virginadentist was present during the evaluations.

Results. All participants (N = 10) completed the assessments. Data analyses, including percentages, frequencies, andmeasures of dispersion, were conducted using the JMP program, version 3.

Conclusions. Conclusions that may be drawn from this study include: 1) study participants who are dependent on thenursing home staff for oral health care needs are most likely to receive oral health care, 2) the quality of oral healthcare performed by the nursing home staff or resident is lower than the current oral health care standards andrecommendations, and 3) study participants' barriers for oral health care were commonly influenced by their physicalfunctioning.

*A modified, one-shot case study is a descriptive analysis of a particular group of individuals within one setting thatreflects moderation, apparent in this study by three discrete visits to the participating nursing home.

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Herbal Alternative Medicine Use in an Urban Dental Hygiene Clinic

Marji J Harmer-Beem, Bernice Mills and David L Baker

Purpose. The purpose of this study was to identify common herbal medicines used and determine the prevalence ofusage among adults attending an urban dental hygiene clinic. There has been a rapid increase in the nationwide useof non-regulated, readily available, herbal alternative medicines. Patients do consider these remedies therapeutic, butnot in the same class as prescription medications. Some herbal medicines show an unfavorable risk-benefit profile,such as bleeding and immunosuppression. Previous studies have shown that patients do not consult their physicianprior to or during herbal medicine consumption.

Materials and Methods. Exempt review was sought and obtained from the institutional review board at the Universityof New England. A records review was conducted for one academic year to determine usage and prevalence of herbalor alternative medicines. Selection criteria included a consecutive sample of all adults 18 years of age and older (N =1,694) from an urban dental hygiene clinic. The sample was taken for two uninterrupted semesters.

Results. Descriptive statistics were used to analyze results for frequency. Of the patients interviewed for prescription,over-the-counter, and herbal or alternative medications, a subset (n = 134) of 8% reported use of herbal or alternativemedicines. This compared to studies reporting national surveys at 9.6%. Results from literature reports range between4.8% and 13.0%. Sixteen herbal alternative medicines were identified as commonly consumed by individual includedin this study. Echinacea, glucosamine, garlic, gingko, ginseng, and brewers yeast were identified as the top six used.Conclusion. People do use herbal medications, some of which can have oral health implications. This study showsusage to be consistently prevalent when correlated with other studies. Dental hygienists should understand and inquireabout usage of herbal medicines. Dental hygienists need to be vigilant when interviewing for herbal or alternativemedication use for safe practice

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Cross-Cultural Adaptability of Dental Hygiene Students andFaculty

Cassandra B Holder-Ballard

University of Tennessee Health Science Center, Memphis

Purpose. Health care educational programs are being urged to produce culturally competent health care providers tomeet the needs of an increasingly diverse U.S. population. The purpose of this study was to first compare the cross-culturaladaptability of first- and second-year dental hygiene students to their faculty; and, secondly, to evaluate the influenceof five demographic variables (age, race, marital/family status, place of residence, and growing up in an ethnicallydiverse community) on cross-cultural adaptability.

Methods and Materials. The Cross-Cultural Adaptability Inventory (CCAI) measures emotional resilience,flexibility/openness, perceptual acuity, and personal autonomy. A demographic survey and the CCAI was administeredto dental hygiene students (N=62) and their faculty (N=16) at a baccalaureate-degree program located in the southeastUnited States. One-way analysis of variance (ANOVA) was used to analyze the data using the Statistical Package forSocial Sciences (SPSS, Chicago, IL). Both the CCAI composite score and the four individual research dimension scoreswere used as dependent variables.

Results. No statistically significant differences were found in the CCAI composite scores between dental hygiene students(juniors or seniors) and faculty. However, an analysis of the four research dimension scores found that the groups(junior dental hygiene students, senior dental hygiene students, and faculty) differed in two areas. For "flexibility andopenness," junior students scored 64.94, seniors scored 65.93, and faculty scored 70.75. Faculty scored significantlyhigher than dental hygiene juniors in this area, P = .036. A significant difference was also found in the area of "personalautonomy" (juniors: 35.36, seniors: 32.76, and faculty: 34.06). Dental hygiene juniors scored significantly higher thansenior dental hygiene students, P = .015. Analysis of the demographic factors found a significant difference in theCCAI composite scores of marital/family status (P < .002). Individuals partnered without children (M = 245) scoredhigher in this sample than those single without children (M = 231) and those partnered with children (M = 218).

Conclusion. In this sample, differences were found in the CCAI scores between students and faculty; and marital/familystatus appeared to be the most significant demographic factor.

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Development of a Standardized Abrasive Scale: An Analysis ofCommercial Prophylaxis Pastes

Karen D Avey, Christina B DeBiase, Marcia A Gladwin, Elizabeth C Kao and Michael D Bagby

West Virginia University

Purpose. Currently, no standard abrasive scale exists for dental prophylaxis pastes. Manufacturers determine theirdefinitions of abrasive grit levels. The purpose of this study was to measure resulting surface roughness on bovineenamel of a representative sample of prophylaxis pastes.

Materials and Methods. The study consisted of an eight-item, descriptive survey of prophylaxis paste manufacturersto gather information, a pilot study to determine testing variables, and an actual analysis of bovine tooth specimens.The sample comprised prophylaxis pastes, pumice, and toothpaste. Pumice was chosen as the standard for abrasivetesting, and toothpaste was selected because it is recommended as an alternative when performing selective polishing.Equipment was constructed for applying a slurry of abrasives to mounted mandibular bovine incisor specimens at 2500rpm for five seconds under a load of 145 g. Seven specimens were subjected to testing for each of the 17 prophylaxispastes, toothpaste, and fine pumice, totaling 133 test specimens. Pretest and posttest surface roughness readings wererecorded using a surface roughness tester equipped with a diamond tip stylus. Repeated measures ANOVA was usedfor statistical analysis to remove the variability from specimen to specimen, so that for each paste the pretest versus theposttest may be evaluated independent of specimens.

Results. Repeated measures ANOVA determined that changes in roughness were significantly different among allpastes (p<.0001). A surface roughness scale of current products was developed and results showed that few pastesactually "polished" and created a smoother surface. When comparing individual pastes to fine pumice, two pastes werefound to have a significantly higher increase in surface roughness, ten showed no significant difference, and six showeda significant decrease in surface roughness.

Conclusions. These results indicated that very few products polished and created a smoother surface. Clinicians mustevaluate individual patients' needs, consider selective polishing, and make evidence-based decisions when choosing aproduct.

Keywords: abrasives, selective , polishing, prophylaxis pastes, enamel surface roughness

Acknowledgements

Funding for this project was provided by the West Virginia University School of Dentistry Research Corporation.

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Oral Health and Pregnancy: An Intervention Study

Barbara C Bush, Linlee Allen, Andi Lindsey and Sara Skelton

Western Kentucky University

Purpose. The research evidence is growing that there is a strong correlation between maternal oral health and adversepregnancy outcomes. The purpose of this study was to evaluate the effect that an informational brochure about therelationship between oral health and pregnancy, given to pregnant women during prenatal visits, had on their attitudestoward seeking oral health care during pregnancy.

Methods and Materials. This pilot study employed a one-shot case study design to examine these variables. Descriptivestatistics were used to provide an understanding of patient attitudes. A facility with 22 different caregivers was selected.Permission was granted to anonymously survey their patients (N=33). Upon checking in for their appointments, thewomen were handed the brochure and asked to read it and respond to the attached questionnaire. The questionnaire,which was not pretested, consisted of three closed-ended questions. Additionally, the caregivers were questioned regardingtheir attitudes and practices on the subject of oral health and prenatal care. The caregivers' questionnaire also consistedof three closed-ended questions.

Results. Results of the survey indicate that 81.8% of the patient respondents plan to seek dental treatment during theirpregnancy and that the brochure influenced this decision in 42.4% of those surveyed. One hundred percent of those[caregivers?] surveyed (N=13) felt that good oral health care is important during pregnancy. Only 53.8% said theycurrently incorporate oral health care and its importance into the prenatal care of their pregnant patients. All caregiverssurveyed (100%) indicated that they would give this information to their patients if it were made readily available.

Conclusions. Results of this study indicate that an informational brochure affects the decision to seek oral health careand that caregivers are receptive to providing this information to their patients if it is readily available. Consideringthe results of this study and the research evidence that supports the correlation between maternal oral health andadverse pregnancy outcomes, it seems prudent to provide prenatal caregivers with informational brochures that couldbe distributed to their patients.

Keywords: Pregnancy, maternal oral health care, prenatal care

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Assessing Activity Level of Sigma Phi Alpha Chapters

Claudine Paula Drew

New Jersey Dental School

Purpose. Sigma Phi Alpha (SPA), the national dental hygiene honor society, strives to promote, recognize, and honorscholarship, leadership, and service among dental hygiene students and the dental hygiene community at large. Theorganizational structure includes the Supreme Chapter, with 190 component chapters located in dental hygiene programsin universities and community colleges. SPA sought to determine why some chapters have high activity levels of inductingnew members, awarding continuing education credits for courses presented, and financially supporting local scholarshiprecipients for academic excellence, while other chapters seem to become weaker and non-functioning over time.

Methods and Materials. A questionnaire was developed to determine the current activity levels of SPA chapters, toassess the inactivity of formerly established chapters, and to collect data on why some dental hygiene programs havenever petitioned for a chapter. Of the 286 questionnaires mailed to U.S. and Canadian schools, 121 were returned(43%).

Results. Approximately one third of the returned questionnaires (41%) indicated that their component chapters' levelsof activity were poor or non-existent. The main reasons given for inactivity were lack of leadership (44%) and no interest(16%), or a combination of the two (28%). The two reasons least given for inactivity were overwhelmed faculty (8%),and a combination of no leader, no meeting place, and no interest (4%).

Conclusions. It was concluded that chapter inactivity resulted mainly from lack of leadership and limited interest. TheSupreme Chapter developed strategies for support and activity improvement. These strategies include 1) betteridentification of inactive chapters; 2) the pairing of a chapter with limited leadership to one with high activity thatwould lend support; and 3) mentoring or coaching of a potential chapter by either the SPA regional trustees or anotherlocal highly functioning chapter.

Keywords: Honor society, organization activity levels, leadership

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A Three-Year Study on the Relationship of an Internal BoardReview Course and Dental Hygiene Student Performance on theNational Board Dental Hygiene Examination

Rhoda Gladstone, Lisa Stefanou and Cheryl Westphal

New York University College of Dentistry

Purpose. The purpose of this study was to determine whether an internal mock board review course (MBC) could helpstudents improve their National Board Dental Hygiene Examination (NBDHE) scores and study skills. This non-credit,pass or fail course was developed as a requirement for graduation.

Methods and Materials. The fall content was based primarily on material from Dr. Esther Wilkins' Clinical Practice

of the Dental Hygienist 8th Edition, along with supplemental Internet information. Multiple mock board quizzes weregiven prior to the end of February, when students must be certified for the spring examination.

Results. Seventy-four students completed surveys at the beginning and end of the fall semester. When three years' worthof MBC scores were compared to actual NBDHE scores, the MBC scores were within five percentage points of theactual NBDHE scores 61% of the time. At the beginning of the MBC, 31% of the students thought they would achievea score of 90% or above on the NBDHE. At the end of the MBC, student surveys indicated that 5% believed they wouldachieve 90% or above. Seven percent of the class actually did achieve above 90%, proving that the course successfullyshowed students the depth of study necessary to score 90% or better. Seventy-nine percent of responding studentsappreciated the "jump start," early study schedule, and review of background material.

Conclusions. The internal board review course motivated students to study earlier than they would have on their own,and our MBC was able to accurately predict which students were ready to take the NBDHE in the spring semester (70%of the class). Because it is critical to find new and innovative ways to motivate students, further study is ongoing toimprove performance for students who did not take the spring NBDHE, and to examine variables that affect studentsuccess

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Infrared Technology: An Adjunctive Instructional Medium

Joy Phipps Gall, Kami M Hanson and Cami Gorringe

Weber State University

Purpose. The ability to effectively detect the position and location of subgingival dental calculus as part of scaling anddebridement procedures is a primary process performed by dental hygienists and, as such, is vital to the periodontalhealth of dental clients. The purpose of this research is to examine the use of infrared technology (IrT) as an educationaladjunct to learning the skill for subgingival calculus detection. It was hypothesized that the use of IrT as a method ofaugmented feedback would increase students' motor skill acquisition for the detection and removal of subgingivalcalculus on patients.

Methods and Materials. The research was an experimental, treatment-control group, comparison design, using 30senior dental hygiene students. The independent variable was the use of IrT for calculus detection, and the dependentvariable was the increase in student motor skill acquisition for calculus detection. Methods for data collection includedstudent-patient encounter forms post-scale, a rubric to evaluate performance for subgingival exploratory instrumentation,and a post-treatment student interview.

Results. The analysis of data revealed a non-statistically significant result in comparison of efficacy for calculus removalbetween groups, t20 = .313, P = .76, 1-tailed and a non-statistically significant result in comparison of exploratory skills,t28 = .611, P = .95, 1-tailed. On the post-treatment interview, 47% supported that motor skills were reinforced with theuse of IrT, 67% supported that IrT validated student findings with a hand-held explorer, 60% supported that the IrTidentified calculus not identified by student, and 60% felt that use of IrT improved motor skills. However, only 27%noted that the use of IrT actually accelerated motor skill development.

Conclusions. In conclusion, researchers failed to reject the null hypothesis. Qualitative evidence suggests that IrT canhave an impact on student motor skill development; however, the research would have to eliminate factors that adverselyimpacted the usage of the IrT. In addition, it is recommended that researchers include an ethnographic inquiry intothe motivations for usage of infrared technology.

Acknowledgements

Funding was provided by Marriott Research and Development Committee, Dr. Ezekiel R. Dumke College of HealthProfessions.

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A Rural School-Based Oral Health Program

Sherry R Jenkins and Kathy V Geurink

The University of Texas Health Science Center-San Antonio

The purpose of this program is to improve the oral health of school-aged children through the development of a modelschool-based oral health program integrated into two existing school-based health centers. Recognizing that dentaldecay is the most prevalent single disease affecting children, and that high-risk populations experience disproportionateamounts of disease, a school-based oral health program represents an ideal mechanism to provide care to children inneed. The pilot program represents a model for development and implementation of a comprehensive school-based oralhealth program in two underserved communities in South Texas. The program is a collaborative effort of the MethodistHealthcare Ministries; the University of Texas Health Science Center at San Antonio Dental School, Department ofDental Hygiene; the Texas Department of Health; community dental clinics; and health professionals, teachers, parents,and administration of the respective schools.

The comprehensive oral health model focuses on the prevention, treatment, and education needs of 9,100 school-agechildren in two school districts. The prevention component includes annual assessments, sealants, fluoride treatments,mouth guard fabrication for sports, oral hygiene instruction, nutrition, tobacco cessation, and early interventionprograms. The treatment component includes essential services such as emergency, diagnostic, preventive, and restorativecare. Oral health education was incorporated into the program for children, parents, and teachers. Dental hygienefaculty and students are providing the preventive treatment and educational services to children at the school-basedhealth centers.

This program addressed Healthy People 2010 objectives in the following areas:

1. Decrease the percentage of children needing urgent dental care. 1,602 children received treatment in the schoolclinic, which included urgent care needs. However, the annual assessment in year three showed a 3% increase in urgentcare needs because of the increased number of new and emergency patients.

2. Decrease the number of children with untreated tooth decay. Annual assessment and screening of 1,208 children inkindergarten and the second, third, seventh, and eighth grades showed a 9% decrease from year one to year three.

3. Increase the percentage of children with annual dental visits. Annual parent survey of children in kindergarten andthe third and eighth grades showed a 2% increase. However, 125 children were seen at the school clinic in year oneand 948 children in year three.

4. Increase percentage of children receiving preventive dental services. In year one, 187 children received services and,in year three, 2,464 received services.

5. Improve oral health knowledge of children and school personnel. Pre- and posttests of students in kindergarten andthe first, second, and third grades and school personnel indicated a 3% to 17% increase in knowledge.

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Acknowledgements

The first three years of the model program were funded by a grant from the Robert Wood Johnson Foundation, andcontinuation funding is being provided by Methodist Healthcare Ministries.



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A Comparison of the Academic Performance of Dental HygieneCertificate and Baccalaureate Students

Holly C Rice and Stewart Turner

University of Texas Health Science Center at Houston, Dental Branch

In 2004, the School of Dental Hygiene at The University of Texas Health Science Center at Houston graduated thefirst class of dental hygiene students with baccalaureate degrees. The purpose of this study was to compare the academicperformance of students in the certificate and the baccalaureate programs. The seventy-four participants were drawnfrom the students in a dental hygiene program at a dental school. The class of 2004 had ten BS and twenty-six certificatestudents. The class of 2005 had twenty-two BS and sixteen certificate students. The pre-requisite grade point averagesand the cumulative grade point averages of students were compared using an analysis of covariance (ANCOVA) todetermine differences. The ANCOVA yielded an F-ratio of 0.071 (Class of 2004 at the end of two years) that was notstatistically significant (p =0.791). The results obtained from the ANCOVA yielded an F-ratio of 0.036 (Class of 2005at the end of one year) that was not statistically significant (p = 0.850). The pre-requisite credit hours and the cumulativegrade point averages were compared also using ANCOVA. The ANCOVA yielded an F-ratio of 0.482 (Class of 2004at the end of two years) that was not statistically significant (p=0.493). The ANCOVA yielded an F- ratio of 0.102 (Classof 2005 at the end of the first year) that was not statistically significant (p=0.751). No differences between the academicperformance of students in the certificate and the BS programs of the class of 2004 or 2005 were found. It could beconcluded from this study that students in the certificate program and the BS program performed similarly. Since theBS program has only been available since 2002, further studies are planned. Permission to conduct this study wasobtained from UTHSC Committee for the Protection of Human Subjects

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Achieving Autonomy in Dental Hygiene Practice through aSchool-Based Oral Health Program

Faith Y Miller, Charla J Lautar, Jennifer M Meyer and Dwayne G Summers

Southern Illinois University in Carbondale

Purpose. Ensuring that all Americans have access to quality oral health care has become the primary focus of local,state, and federal government agencies; and the issue has also been placed on numerous legislative agendas. Thepurpose of the school-based project at the Southern Illinois University Carbondale (SIUC) Dental Hygiene Program(DHP) was to assist in meeting the goals outlined in the Oral Health in America: The Report of the Surgeon General,Healthy People 2010 (HP 2010), the Illinois Oral Health Plan (IOHP) and A National Call to Action to Promote OralHealth. Dental hygiene (DH) students play a significant role in meeting current access issues. Recent legislation inIllinois has allowed registered dental hygienists (RDHs) to practice under the general supervision of a dentist.

Significance. To close the gap in the disparities concerning access to care, DH students have been utilized in multiplesettings beyond the traditional and institutionally-based dental hygiene clinic. DH students are being used to staffschool-based dental sealant programs as well as safety-net clinics serving a more diverse population including thoseclients with special needs. Since the students are still matriculating through school, relaxation of the supervision lawshave increased the opportunities for those needing the most care to be seen and subsequently treated in facilities orremote sites by DH students who are supervised by the RDH. To date, the Dental Sealant Grant Program (DSGP) atSIUC has seen well over 250 what is considered at-risk, low-income children, placed approximately 400 sealants andhas established a referral system for children requiring urgent or routine care through the campus-based CommunityDental Center (CDC) and the Illinois Children's Health Foundation (ICHF), which is an extension of the CDC. Bothclinics utilize DH students as primary clinicians, supervised by the DH program faculty. This approach to treatment,lends itself to meeting the oral health needs of the population through effective collaborations and partnering withentities within the community that continually seek such services as highlighted in the Surgeon General's Report onOral Health, in addition to the IOHP. Conclusion: The SIUC DSGP employs the utilization of dental hygiene studentsunder the general supervision of the RDH. The school-based oral health program can serve as one small step towardsachieving autonomy in dental hygiene practice.

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A Pilot Study of the Effects of a Natural Mineral DietarySupplement on Gingival Health and Dentinal Hypersensitivity

Ellen J Rogo, Kathleen O Hodges and Anita Herzog

Idaho State University

Purpose. A natural mineral dietary supplement containing 3.6 mg/liter of fluoride and other minerals (pH 9.6) wasstudied to determine the effects of drinking the product on dentinal sensitivity and gingival health. The companydistributing the supplement,had received unsolicited claims of improvement of oral health and tooth sensitivity fromindividuals who consumed the product. This pilot study evaluated the clinical validity of the anecdotal claims.

Methods and Materials. Subjects included in the study had minimum levels of dentin sensitivity and gingivalinflammation. The investigation was a quasi-experimental pretest design with repeated posttest measurements at fourand eight weeks. A randomized, controlled, double-blind approach was used. The experimental and control groupsfollowed the same regimen for drinking and swishing the product, with the only difference being the contents in thebottle (the supplement or a placebo containing de-ionized water). Dentin sensitivity was measured on a visual analoguescale from 0 to 10, using an explorer to determine tactile sensitivity and a blast of air to determine evaporative sensitivity.The Gingival Index (GI) was used to measure gingival inflammation. These data were analyzed using ANOVA and apost-hoc probing technique to determine within and between group differences, at a P=0.05 level.

Results. Both groups experienced a statistically significant decrease in tactile and evaporative sensitivity over theeight-week study; however, the differences between groups were not significant. No significant differences were foundin regard to gingival inflammation.

Conclusions. The natural mineral dietary supplement and the de-ionized water were equally effective in reducing dentinsensitivity, and neither product had an effect on gingival inflammation.

Acknowledgements

Funding for this project was provided by the National Medical Device Survey (NMDS).

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Kentucky's Oral Health Wellness and Disease PreventionProgram: An Innovative Partnership

Sharlee M Shirley

University of Kentucky

Developing unique and varied partnerships to reach at-risk kids and communities is key to tackling current and futureoral disease. According to the 2001 Kentucky Children's Oral Health Profiles, in which 5,603 third- and sixth-gradechildren in Kentucky's public schools were screened, 28.7% had untreated tooth decay. The Kentucky Oral HealthWellness and Disease Prevention Program began with an objective to develop a statewide 4-H camp program focusingon oral health wellness, disease prevention, tobacco education, and the promotion of oral health professions amongpreteen and teenage campers.

The University of Kentucky College of Dentistry, Divison of Dental Public Health, agreed to collaborate with the 4-Hprogram at the College of Agriculture Extension Service by providing a research title faculty member to develop andimplement the pilot 4-H camp program for four camps in the summer of 2003. The overwhelming success of the pilot4-H camp initiative in 2003 led to the program expanding to nine camps in 2004. More notable, however, it precipitateda unique partnership between the two colleges. The jointly appointed faculty member focused on developing oral healthwellness and disease prevention resources for extension agents to use on a county-by-county level to educate, promoteoral wellness, remove barriers to access, and create a pipeline of oral health professionals from rural communities.

The initial findings of the Kentucky Oral Health Wellness and Disease Prevention Program indicate that networkingconducted between non-traditional partners can produce original, expectantly sustainable programs that benefit allcounties of the Commonwealth and each family within, while leading the country in innovative approaches to oralhealth wellness, education, and disease prevention.

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Medication Compliance in the Older Adult Patient

Adele Spencer and Maureen Tsokris

Farmingdale State University of New York

Purpose. The purpose of this study was to determine the level of medication compliance in the older adult dental patient.The ultimate goal of the research was to promote awareness among dental hygiene practitioners of the number ofprescription, over-the-counter, and herbal medications used by this population.

Methods and Materials. Self-report questionnaires were distributed randomly to older adults, with the median age rangeof 76 to 84, attending local community meetings (n=114). All responses were anonymous. A statistical package (SPSSversion 12.0, Chicago, IL) was used to execute basic descriptive statistics including frequency distribution, percentages,means, and standard deviations.

Results. Of the 115 surveys distributed, one survey was rejected. Among the respondents, 93% reported taking prescriptionmedication, 63% reported taking over-the-counter drugs, and 23% reported taking herbal medications. Twenty-ninepercent took four to six medications daily, and 21 % took more than seven medications daily. Nearly one quarter of therespondents surveyed reported that they had missed a dose, while 15% stated that they had stopped taking medicationbefore their prescription was completed. Similarly, 14% responded that they had forgotten to fill or refill a prescription,while 13% stated they had taken less medication than prescribed. Of significance to oral health practitioners, 35% ofrespondents indicated that their dentists or dental hygienists did not ask them when they last took their medications.

Conclusions. It can be concluded from this study that older adult dental patients are utilizing large numbers ofprescription, over-the-counter, and herbal medications; and that medication compliance issues relative to the practiceof dental hygiene exist.

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Stroke Risk Assessment in a Southeastern University DentalHygiene Facility

Barbara G Tanenbaum and Suzanne M Edenfield

Armstrong Atlantic State University

Purpose. The purpose of this study was to identify significant stroke risk factors, which may assist dental hygienestudents in educating the clinic population on methods of stroke prevention. The southeastern United States is referredto as the "Stroke Belt," with Georgia having a 14% higher rate of cardiovascular death and the sixth highest mortalityrate among the 50 states. It is postulated that the death rates attributed to this disease are associated with preventablerisk factors such as hypertension, diabetes, cigarette smoking, cardiovascular disease, atrial fibrillation, and lack ofphysical activity.

Methods and Materials. Because statistics reveal a disproportionately high incidence of stroke in this region of thecountry and risk factors have been identified, this study was conducted on a southeastern Georgia population at theArmstrong Atlantic State University (AASU) campus. The dental hygiene department clinic served as a screening facilityfor the American Stroke Association's Southeast Affiliate Operation Stroke project, with services predominately utilizedby persons with low income, no insurance, and/or lack of regular health care. Utilizing a written survey for stroke riskassessment and descriptive statistics, data was analyzed to determine age, race, gender, and quantifiable stroke riskfactors.

Results. Using one-way ANOVA statistical analysis, the data demonstrated that, of the 144 surveyed, a higher percentageof subjects with a history of diabetes had a moderate stroke risk; whereas a larger percentage of non-diabetics was atlow risk. Additionally, subjects who were smokers or had cardiovascular disease or atrial fibrillation were at a significantlygreater risk of stroke. Subgroup analyses revealed significant differences between groups in the prevalence of riskfactors, suggesting that blacks, even those on blood pressure medicine, had a significantly higher blood pressure (P<.046) than whites. However, because this number of subjects was low (n=5), one should be cautious in drawingconculsions. Additionally, the data indicated no significant differences between gender on any of the risk factors.

Conclusions. Based upon the results, educational information pertaining to stroke risk factors was incorporated intothe curriculum in an effort to reduce the stroke incidence in the population utilizing the AASU dental hygiene clinic.

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Oral Cancer Prevalence in Virginia

Karin C Loftin, Michele Darby, Stacey Plichta, Sophie Thompson, Shreeram Kumar and Louis Abbey

Karin C. Loftin, PhD; Michele Darby, BSDH, MS; Stacey Plichta, ScD; and Sophie Thompson, MHS, CT (ASCP) (IAC), are professorsat Old Dominion University. Shreeram Kumar, PhD(c), is a doctoral student at Old Dominion University. Louis Abbey, DMD, is aprofessor at Virginia Commonwealth University.

Purpose. Oral and pharyngeal cancer affects 30,000 Americans a year and kills one fourth of those diagnosed. Theprimary risk factors for oral cancer are past or present cigarette and tobacco usage, and alcohol consumption inconjunction with tobacco use. Even though the prevalence of oral cancer is relatively low in the younger age groups,this group is most likely to benefit from intervention programs designed to change risky behavior such as smoking, andto prevent oral cancer in the later years. The goal of the study was to identify high-risk target areas for an oral cancerprevention program in Virginia.

Methods and Materials. The specific objectives were to analyze the 1986 to 2001 Oral Biopsy Database from the VirginiaCommonwealth University School of Dentistry for diagnosed cases of oral cancer. To test the hypothesis that HamptonRoads, Virginia would be a high-risk target area, diagnoses were correlated with the 11 zip-code regions in Virginiato identify specific geographical areas with high numbers of oral cancer cases. The oral cancer data set consisted of4,712 cases. Frequencies and cross-tabulations were calculated for all the variables using Statistical Package for SocialScientists software (SPSS Inc., version 10.1, Chicago, IL).

Results. Results indicated that the Hampton Roads region had the second highest number of squamous cell carcinomas,with 231 total cases. The Richmond area had 435cases, almost twice as many.

Conclusions. Therefore, Hampton Roads and Richmond are high-risk target areas that would benefit from an aggressiveoral cancer prevention and intervention program in its public schools.

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Implementing Survey Research into Strategic Planning Activitiesin Idaho to Advance the Science and Practice of Dental Hygiene

Kathleen O Hodges and Kristin H Calley

Idaho State University

Purpose. For strategic planning, the Idaho Dental Hygienists' Association uses survey methodology to identify theopinions and concerns of dental hygienists. This study aimed to assess dental Hygienists' opinions about advanceddental hygiene practice and legislative activities.

Methods and Materials. In 2002, a coded questionnaire was mailed to Idaho dental hygiene licensees (N = 865). SectionI addressed demographic characteristics. Section II surveyed professional concerns, illegal practice, and legislativeactivities. Respondents were asked to rank 14 professional issues by selecting their top five concerns about dentalhygiene practice. Also, respondents were asked if they supported expanding the scope of practice and if they wouldprovide care in alternative practice settings. Data were analyzed using frequency distributions and nonparametric testsof association.

Results. A 60% (N = 519) response rate was obtained after two mailings. Three professional issues were ranked asfollows: 1) the national trend to reduce entry-level education (64.9%), 2) dental assistants performing dental hygieneservices (61.1%), and 3) legalizing self-regulation (49.8%). Also, 90.9% (n = 460) of respondents supported the expansionof the practice act to improve access to care. Unsupervised practice in public health settings was most important (95.4%),and local anesthesia administration under general supervision was second most important (88.9%). Unsupervisedpractice in all settings was ranked third most important (85.2%), and providing restorative services was the fourth mostimportant (81.7%) practice act expansion identified. Eighty-nine percent supported having a bachelor's degree toprovide unsupervised care. Data were used to support the 2004 legislation to expand the dental hygiene practice act.

Conclusion. It is vital for state professional associations to utilize information from licensees for strategic planningand legislative efforts. Idaho dental hygienists are concerned about maintaining quality education, expanding accessto care to the underserved, providing restorative services, and educating dental personnel about state laws.

Acknowledgements

Funding for this project was provided by an ADHA Kaleidoscope Grant.

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